HospitalInspections.org

Based on observation and interview, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by failing to ensure that all 10 patient beds in the inpatient geriatric psychiatric unit were free from ligature risks.
Findings:

Observations on 06/04/18 at 12:10 p.m. with S1CNO revealed that all 10 beds in the unit had multiple ligature points. Further observations revealed that the foot-end of the beds could be raised and fixed in the raised position with the attached metal adjustment bar. The 200 pound surveyor sat on the raised end of one of the beds and it did not fall, holding all of his weight. S1CNO confirmed the ligature risk.

On 06/04/18 at 12:30 p.m., S1CNO acknowledged the multiple ligature points on all 10 patient beds in the unit.

Based on observation, record review and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to ensure that physician orders were followed for obtaining lab glucose results for a patient who had fingerstick blood glucose readings above 400 (Patient #2);
2) The RN failed to ensure that patients with orders for telemetry monitoring were monitored at all times and telemetry strips were analyzed by a competent RN and
3) The RN failed to ensure that physician orders for Versed and Diprovan drips were clarified and followed for 1 of 1 patient reviewed for continuous medication infusions (Patient #21).
Findings:

1) The RN failed to ensure that physician orders were followed for obtaining lab glucose results for a patient who had fingerstick blood glucose readings above 400 (Patient #2)

Review of the medical record for Patient #2, with S1CNO, revealed an admit date of 06/04/18 with diagnoses including chest pain and diabetes. Review of the admission orders revealed orders to obtain fingerstick blood glucose checks before meals and at bedtime. Further review of the orders revealed Humulin R insulin was to be administered per the physician's protocol. This protocol revealed that if fingerstick glucose was above 400, administer 12 units of Humulin R insulin and obtain lab glucose; repeat lab glucose in one hour. If no change, call physician.

Review of the patient's fingerstick blood glucose results revealed the following:
06/04/18 at 9:42 p.m. - 438. The nurses notes revealed "12 units given and snacks left at bedside". There was no documented evidence that lab glucose results were obtained for the fingerstick glucose over 400 per physician orders.

06/05/18 at 5:38 a.m. - 421. The nurses notes revealed " 12 units given". There was no documented evidence that lab results were obtained per physician orders.

On 06/06/18 at 1:30 p.m., S1CNO confirmed that the physician orders for lab draws for blood glucose over 400 was not followed.

2) The RN failed to ensure that patients with orders for telemetry monitoring were monitored at all times and telemetry strips were analyzed by a competent RN

Review of the hospital policy titled, Telemetry-Monitoring Station, revealed in part that the ICU nurse/monitor tech will monitor and respond to the central monitor alarms. One rhythm strip per 4 hours will be printed and documented in the patient's medical record. Each strip will be analyzed by a competent RN and will include: heart rate, QRS width and QT and PR intervals, identification of the rhythm, any ectopy, heart rate alarm parameters.

On 06/04/18 at 11:00 a.m., observation in the ICU unit revealed that the telemetry monitoring station for all hospital inpatients was in the ICU nurses station. Observation revealed the nurses in the ICU would sit at the monitor station at times, but no staff was at the telemetry monitor at all times. Interview with S1CNO at this time revealed that the nurses in ICU monitor all patients on telemetry at the hospital. She further stated that the ICU has a monitor tech on evenings and on weekends only. When asked who monitors the patient's telemetry monitors when there is no tech, she stated that the RNs are to monitor. When asked if the telemetry monitors were monitored at all times, she stated no.

On 06/06/18 at 11:00 a.m., review of patient #1's electronic medical record, with S1CNO, revealed the patient had an order dated 06/02/18 for telemetry monitoring. Review of the record revealed that telemetry strips were documented in the medical record every 4 hours but there was no documented evidence that they were analyzed by an RN. At this time, interview with S1CNO revealed that the telemetry stips of the patients who are not in ICU are not analyzed by an RN.

3) The RN failed to ensure that physician orders for Versed and Diprovan drips were clarified and followed for 1 of 1 patient reviewed for continuous medication infusions (Patient #21)

Review of the electronic medical record for Patient #21, with S1CNO, revealed an admit date of 04/26/18 with diagnoses including sepsis and pneumonia with respiratory failure. Review of the physician orders revealed the patient was intubated and had orders for "Diprovan 10mg/mL IV PRN" dated 04/27/18 at 3:49 p.m. There were no orders regarding the dosage or titration of the Diprovan. Further review of the record revealed that "Versed infusion 4mg IV PRN" was ordered on 04/27/18 at 4:12 p.m. There were no parameters for the dosage of Versed.

Review of the nurses notes dated 04/27/18 at 7:10 p.m. (first notation of Diprovan and Versed) revealed Diprovan infusion at 15mcg/kg/min and Versed at 2mg/hr infusing.

On 06/06/18 at 2:20 p.m., interview with S1CNO confirmed that the orders for Diprovan and Versed should have been clarified with the physician. S1CNO further stated that the Versed infusion dose was not administered per physician orders.

Based on record review and interview, the nursing staff failed to administer medications in accordance with physician orders and hospital policies and procedures by failing to conduct pain assessments prior to and/or after administering pain medication for 2 of 2 patients (Patient #1, 3) reviewed for PRN pain medications in a total sample of 32.
Findings:

Review of the hospital policy titled, Pain Management, Documentation and Follow up, revealed in part that the nurse should use a pain scale to assess the patient's pain level prior to administering pain medication. Once oral pain medication is given, the nurse should return to the patient within 30-45 minutes to see if the medication was effective in controlling the patient's pain. This information should be documented in the patient's chart as follow-up.

Patient #1
Review of the electronic medical record, with S1CNO, revealed an admit date of 06/02/18. Review of the physician admission orders revealed Tylenol with Codeine, 10 mL every 6 hours was ordered PRN. The order did not specify the parameters for which the PRN medication should be administered.

Further review of the record revealed that the patient received the PRN Tylenol with Codeine on the following dates:
06/02/18 at 1:33 a.m. - There was no follow-up documented in the record regarding the effectiveness of the medication.
06/02/18 at 12:24 p.m. - There was no follow-up documented in the record regarding the effectiveness of the medication.
06/02/18 at 8:55 p.m. - There was no pain assessment documented prior to administering the medication.
06/03/18 at 3:33 a.m. - There was no follow-up documented in the record regarding the effectiveness of the medication.

Patient #3
Review of the electronic medical record, with S1CNO, revealed an admit date of 06/02/18. Review of the physician admission orders revealed Norco 5/325 every 6 hours PRN pain was ordered.

Further review of the record revealed that the patient received the PRN Norco on the following dates:
06/02/18 at 2:43 a.m. - There was no pain assessment documented prior to or after administering the PRN medication.
06/02/18 at 8:58 a.m. - There was no follow-up documented in the record regarding the effectiveness of the medication.
06/02/18 at 9:21 p.m. - There was no pain assessment documented prior to or after administering the PRN medication.
06/03/18 at 9:51 p.m. - There was no follow-up documented in the record regarding the effectiveness of the medication.
06/04/18 at 6:16 p.m. - There was no pain assessment documented prior to administering the PRN medication.

On 06/05/18 at 3:00 p.m., interview with S1CNO confirmed that the above patients did not have pain assessments performed prior to and/or after administering PRN pain medications.

Based on record review and interview, the hospital failed to ensure the clinical records system was maintained in accordance with written policies and procedures. This deficient practice was evidenced by failure of the hospital to ensure patient medical records were promptly completed as set forth in the hospital's policies for completion of medical records and failure to enforce consequences for delinquent medical records as set forth in the hospital's Medical Staff Bylaws.
Findings:

Review of the hospital's Medical Staff Bylaws revealed the included the following: The medical record shall be completed in its entirety, dictations complete and authenticated, within 30 days of the patient's discharge. Medical records containing deficiencies greater than 30 days shall be deemed delinquent.

The Medical Staff Bylaws further revealed that physician with an incomplete record(s) 30 days old will be notified by the hospital administration that the record(s) is available for completion. The physician shall have a one week grace period in which to complete the record(s). If the record(s) remains incomplete at the end of the grace period, the hospital administrator at his discretion shall send the physician a certified letter advising that if the record is not completed within seven days from the date of notice the physician's clinical privileges are automatically suspended.

Review of the hospital's medical record deficiency report, provided as current by S2COO, revealed the hospital had 24 delinquent medical records with patient discharges dating back to 01/01/18. These included:
5 medical records greater than 120 days deficient
1 medical record greater than 90 days deficient
9 medical records greater than 60 days deficient
9 medical records greater than 30 days deficient

In an interview on 06/05/18 at 10:15 a.m. with S2COO, she stated that she emails the physicians with delinquent medical records weekly. She further stated that no certified letters regarding deficient patient records had been sent to the physicians with delinquent records. S2COO reported there had been no suspension of any physician privileges for incomplete charts as referenced in the hospital's Medical Staff Bylaws.

Based on record review and interview, the hospital failed to ensure a medical history and physical examination was completed and placed in the patient's medical record within 24 hours after admission for 1 (#26) out of 32 sampled records reviewed.
Findings:

Review of Patient #26's medical record revealed an admit date of 5/30/18. Further review failed to reveal a medical history and physical was in the chart.

During an interview on 6/6/18 at 9:50 a.m., S8Infection Control acknowledged Patient #26's medical record did not contain a medical history and physical.

Based on record review, observation, and interview, the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not be available for patient use.
Findings:

Review of the hospital's policy titled, Medication Administration, revealed, in part, the following: Once a multiple dose vial has been punctured in preparation to administer the medication, the vial shall be re-labeled with the revised expiration date of 28 days past the opened date.

On 06/04/18 at 11:30 a.m., observation of the medication refrigerator in the ICU revealed the following:
1 opened Lantus insulin vial with no open date labeled on the vial
1 opened Levemir vial with open date labeled 04/27/18

S1CNO was present during the above observations. S1CNO confirmed that the above multi dose vials of medication should not have been available for patient use, due to being expired or not properly labeled.

Based on hospital policy, record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's electronic medical record for 3 of 3 patients (#6, #29, #30) reviewed who had hospital identified medication errors.
Findings:

Review of the hospital's policy revealed, in part, the following:
Subject: Medication Administration
Errors in administration of medication shall be reported immediately to the attending physician...
The actual medication administered shall be documented on the medical record.

Review of the hospital's Medication Error Form dated 12/7/17 revealed Patient #29 was given Flagyl 500mg instead of Rocephin 500mg.

Review of Patient #29's medical record failed to reveal the medication error documented in the patient's chart.

Review of the hospital's Medication Error Form dated 1/1/18 revealed Patient #30 was not given their 11:00 p.m. dose of Merrem 1 gram.

Review of Patient #30's medical record failed to reveal the medication error documented in the patient's chart.

Review of the hospital's Medication Error Form dated 1/3/18 revealed Patient #6 did not receive their 1/2/18 4:00 a.m. dose of Zithromax 500mg.

Review of Patient #6's medical record failed to reveal the medication error documented in the patient's chart.

During an interview on 6/6/18 at 10:10 a.m., S8Infection Control acknowledged the medication errors for Patients #6, #29, and #30 were not documented in the patient's charts.

Based on observations, interviews, and policy review the hospital failed to ensure an effective system was in place for the proper routine storage of trash and biohazardous waste. This was evidenced by the hospital's Bio- Hazard Storage Shed door being unlocked and the shed contained hazardous material.
Findings:

Review of the hospital policy titled "Contaminated Trash", Reference Number HSK 2001, revealed in part: The employee will transport the bio-hazard trash/ containers to the Bio-Hazard holding room, outside the main facility. The housekeeper will ensure that the holding room is locked at all times. All bio-hazard trash will be stored in the holding room for pick-up.

An observation of the Hazardous Waste Shed on 6/5/18 at 11:40 a.m. revealed the door was unlocked and the shed contained hazardous waste in red bags and filled sharps containers.

In an interview on 6/5/18 at 11:40 a.m., S14Housekeeping Manager verified the door to the hazardous waste shed was unlocked and the shed contained hazardous waste material. She also verified the policy requires the door to remain locked.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by:
1) failing to ensure the functionality of a nurse call button located on the handrails of 6 of 6 patient beds in the ICU with call buttons on the hand rails; and
2) failing to ensure crash carts in the Emergency Department were checked daily for defibrillator function and appropriate stock.
Findings:

1) Failing to ensure the functionality of a nurse call button located on the handrails.

On 06/04/18 at 11:15 a.m. an observation was made of the hospital's ICU with S1CNO. The observation revealed that the unit contained 4 ICU beds and 2 step-down beds. Observations revealed that all beds had a non-functional nurse call feature on the siderail of the bed. When the button was pressed on the side rail, no alert of any type was generated.

At that time, S1CNO confirmed that the nurse call feature on the siderails of the above 6 beds was not functional. She reported patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient's bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family/visitor confusion with having the non-functional nurse call feature available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. S1CNO indicated she understood what the surveyor was saying when asked if having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance.

2) Failing to ensure crash carts in the Emergency Department were checked daily.

An observation of the Emergency Department on 6/4/18 at 3:15 p.m. with S3RN, revealed the following:
a. Trauma Room 1 Adult and Pediatric Crash Cart check for functionality of the defibrillator, cart locked and the cart being appropriately stocked was not completed for 6/2/2018 and 6/3/2018.
b. Trauma Room 2 Adult Crash Cart check for functionality of the defibrillator, cart locked and the cart being appropriately stocked was not completed for 6/2/2018 and 6/3/2018.

A review of the hospital policy titled "Crash Carts- Adult and Pediatric", Policy # ED1229 revealed in part: Crash carts will be checked daily: check defibrillator, check if cart is locked and check stock sheet, or after each code.

In an interview on 6/4/18 at 3:15 p.m. S3RN verified the night shift staff is required to check the crash carts and document the checks every night.


38777

36293

Based on observation, record review, and interview, the infection control officer failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by failure to maintain a sanitary environment.
Findings:

A) Tour of facility with S1CNO revealed the following:
Observation of ICU (Intensive Care Unit) on 6/4/18 at 11:15 a.m. revealed the following:
a. Room a - two armchairs with tears/rips on their vinyl covering.
b. Room b - one armchair with tears/rips on their vinyl covering.
c. Room c -one armchair with tears/rips on their vinyl covering.
d. Room d - one armchair with tears/rips on their vinyl covering.

During an interview on 6/4/18 at 11:35 a.m., S1CNO acknowledged the furnishings in the patient's rooms with the tears/rips on the vinyl covering could not be sanitized and were an infection control issue.

Observation on 6/4/18 at 11:40 a.m. of the clean equipment room revealed the following:
a. 3 - dirty infusion pumps stored in the clean equipment equipment room.
b. Baby bed with a soiled mattress stored in the clean equipment room.

During an interview at this time, S1CNO acknowledged the soiled baby bed and storing dirty and clean equipment together were infection control issues.

Observation on 6/4/18 at 11:45 revealed the following:
a. Room e - sofa with tears/rips to the vinyl covering on the arms and tears/rips to the coverings on the armchair.
b. Room f - sofa with tears/rips to the vinyl covering on the arms.
c. Room g - sofa with tears/rips to the vinyl covering on the arms.
d. Room h - sofa with tears/rips to the vinyl covering on the arms.

During an interview on 6/4/18 at 12:00 p.m., S1CNO acknowledged the furnishings in the patient's rooms with the tears/rips on the vinyl covering could not be sanitized and were an infection control issue.

Observation on 6/4/18 at 12:05 p.m. of the nurse's station medication room revealed a pill cutter with powdered medication residual remaining on the surface.

During an interview on 6/4/18 at 12:07 S9LPN acknowledged the pill cutter had not been sanitized.

B) Review of the hospital's policy titled "Housekeeping Procedures in the OR" revealed, in part, the following:
Purpose: To provide, through established practices, policies and schedules, relevant cleaning measures for the control and prevention of infection in the surgical suite.
Policy: Housekeeping procedures include cleaning and disinfection of the surgical suite and disposal of soiled linen and solid wastes. These procedures are performed by Surgical personnel.
Procedures: Trash, linen and instruments, ...are placed in red containers and removed by Housekeeping for transport to the soiled utility room.

During an interview on 6/5/18 at 10:08 a.m., S13Surgery Tech stated they do not have any surgery cases scheduled for today and the operating rooms were terminally- cleaned after the last case yesterday.

a. Tour of operating rooom i with S13Surgery Tech on 6/5/18 at 10:10 revealed the following:
b. Arm-board and pillow case on the floor
c. Both arm-boards noted with tears/rips to the vinyl covering.
d. Two transducer brackets with grime and dust noted on the surfaces
e. Two portable vacuum-container stands with hair, grime and dust noted on the surfaces
f. Dirty scissors and needle caps noted on the top of the laparoscope tower.
g. Hair and grime on the front ledges of the laparoscope tower.
h. Dirty scissors and towel clamps on the top shelf of ventilator.
i. Dried brownish residue on the warming blanket exhaust tubing.

During an interview on 6/5/18 at 10:30 a.m., S13Surgery Tech acknowledge the findings in operating room i and acknowledged the findings were an infection control issue.

C) An observation of the kitchen on 6/5/18 at 8:30 p.m. revealed the following:
a. Four of four ceiling mounted air vents were contained a brown substance and fuzzy material;
b. The walls contained a greasy substance and dust particles;
c. The metal spice rack, utensil rack and paper goods rack contained a sticky substance and dust particles;
d. The table mounted can opener contained residue and build up on the base and blade mount;
e. The Clean Dish Dry Rack contained a sticky substance and dust.

In an interview on 6/5/18 at 8:30 a.m. S4Maintenance Manager and S5Dietary Manager, verified the aforementioned concerns and S4Maintenance Manager stated he could not tell me when was the last time the vents and air filters were changed.

D) Observation on 6/6/18 at 11:05 a.m. with S6OT of the Rehabilitation Department revealed the following:
a. Exam room with tears/rip to vinyl covering of the sofa, Dirty sheets on the bed and a dirty gown left in the room.
b. Heated parafin basin with visible particles in the botton
c. Hydropack covers stored wet on an exam table
d. Arm chair with tears/rips on the arm coverings

During an interview on 6/6/18 at 11:20 a.m., S6OT acknowledged the findings in the Rehabilitation Department and acknowledged the findings were an infection control issue.

Review of Hydropack water tank record failed to reveal a current temperature and disenfecting log. June 2017 was the most current record provided by S6OT.

S6OT was unable to provide a record of sanitation for the heated parafin device.


38777

Based on record review and interview, the hospital failed to address, in the swing bed patient's rights and notify swing bed patients, of the right to refuse to perform services for the facility; perform services for the facility, if he or she chooses when the facility has documented the need or desire to work in the plan of care. This was evidenced by the hospital failing to include the provision for work in the Patient Rights and Responsibilities, which is given to the swing bed patients upon admission.

Findings:
Review of the Patient Rights and Responsibilities document, presented by the hospital as the current patient right given to all patients (acute inpatient and swing bed) revealed no documented evidence for swing bed patient's rights regarding work.

During an interview on 6/6/18 at 3:00 p.m., S15Case Manager acknowledged the patient's rights regarding work were not included in the rights provided to the swing bed patients.

Based on record review and interview, the hospital failed to address, in the swing bed patient's rights and notify swing bed patients, of the right to send and promptly receive mail that is unopened and to have access to stationery, postage, and writing implements at the patient's own expense This was evidenced by the hospital failing to include this right in the Patient Right and Responsibilities which is given to the swing bed patients upon admission.

Findings:

Review of the Patient Rights and Responsibilities document, presented by the hospital as the current patient right given to all patients (acute inpatient and swing bed) revealed no documented evidence for swing bed patient's rights regarding mail.

During an interview on 6/6/18 at 3:00 p.m., S15Case Manager acknowledged the patient's rights regarding mail were not included in the rights provided to the swing bed patients.

Based on record review and interview, the hospital failed to address, in the swing bed patient's rights and notify swing bed patients, of the right retain and use personal possessions, including some furnishings, and appropriate clothing as space permits. This was evidenced by the hospital failing to include this right in the Patient Right and Responsibilities, which is given to the swing bed patients upon admission.

Findings:

Review of the Patient Rights and Responsibilities document, presented by the hospital as the current patient right given to all patients (acute inpatient and swing bed) revealed no documented evidence for swing bed patient's rights regarding personal possessions.

During an interview on 6/6/18 at 3:00 p.m., S15Case Manager acknowledged the patient's rights regarding personal possessions were not included in the rights provided to the swing bed patients.

Based on record review and interview, the hospital failed to address, in the swing bed patient's rights and notify swing bed patients, of the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. This was evidenced by the hospital failing to include a provision for married couples in the Patient Right and Responsibilities, which is given to the swing bed patients upon admission.

Findings:

Review of the Patient Rights and Responsibilities document, presented by the hospital as the current patient right given to all patients (acute inpatient and swing bed) revealed no documented evidence for swing bed patient's rights regarding married couples.

During an interview on 6/6/18 at 3:00 p.m., S15Case Manager acknowledged the patient's rights regarding married couples was not included in the rights provided to the swing bed patients.

Based on record review and interview, the hospital failed to address, in the swing bed patient's rights and notify the swing bed patients, of the right to remain in the facility, and not transfer or discharge the resident from the facility unless their transfer or discharge is: necessary for resident's welfare and needs cannot be met in the facility; appropriate because the resident's health has improved sufficiently so the resident no longer needs their services; the safety of individuals in the facility is endangered; the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility, in the Patient Right and Responsibilities which is given to the swing bed patients upon admission.

Findings:

Review of the Patient Rights and Responsibilities document, presented by the hospital as the current patient right given to all patients (acute inpatient and swing bed) revealed no documented evidence for swing bed patient's rights regarding transfers or discharges.

During an interview on 6/6/18 at 3:00 p.m., S15Case Manager acknowledged the patient's rights regarding transfers and discharges was not included in the rights provided to the swing bed patients.