HospitalInspections.org

Based on review of medical staff bylaws, policies and procedures, medical records, and interviews, it was determined the Hospital did not require the physician write a restraint order for 1 of 3 patients (Patient #29).

Findings include:

Patient #29, was admitted to the facility on 07/13/11, for carotid stenosis with blockage. The patient underwent a stent placement and repair of the right carotid artery.

The hospital policy/procedure titled "Restraint Use in Non Violent Situations" requires: "...Obtain an order...episode of restraint...Re-assess the patient every 2 hours...based on the individual needs of the patient...."

Review of the patient's Restraint/Seclusion Assessment dated 07/19/11, revealed RN #17, documented the patient's right arm with a soft restraint because the patient had continuing behavior of pulling at "Therapy."

The patient's Restraint/Seclusion Assessment dated 07/29/11, revealed RN #31, documented the patient's right and left arm with soft restraints due to failure to meet criteria for removal.

The Quality Specialist and Intensive Care Nurse (ICU) RN #17, confirmed during an interview on 10/26/11, there was no physician order for the initiation of restraints during Patient #29's hospitalization.

Based on review of facility policies and procedures, observation on tour, and interview with the staff, it was determined the facility failed to require staff to wear appropriate personal protective equipment (PPE) in the patient's room during hemodialysis treatment.

Findings include:

Review of facility policy, "Hemodialysis: Infection Prevention for Hemodialysis and Apheresis," revealed: "...Personal Protective Equipment (PPE) shall be used by personnel where exposure to blood is likely to occur, especially during initiation and termination of procedures...Masks, eye protection, and face shields are required for vascular access, initiation and termination of dialysis or Apheresis...gowns or other protective body clothing shall be used when it is reasonably anticipated that exposure to blood, other infectious material or body fluids could result in contamination or personnel clothing...."

Observation on 10/26/11 at 0855 hours, revealed RN employee #15 accessing the left upper arm graft for patient # 18 without wearing a face shield and gown.

RN employee #15 confirmed that a gown is only worn when the patient is on isolation and own personal glasses are worn in place of a face shield.

The infection control nurse, employee #14 confirmed in an interview conducted on 10/26/11 at 1350 hours, that the RN should wear a gown and face shield when initiating access site and when taking the patient off the machine.

The Quality Management Director, RN employee # 2, confirmed on 10/26/11 at 1600 hours, that PPE is required when initiating and ending an access site for hemodialysis.

Based on review of policies and procedures, medical records, and interview, it was determined the Hospital failed to require RN's:

1) administer sliding scale insulin to 3 of 5 patients requiring coverage for elevated blood sugars (Patients #21, 27, and 29);

2) document chest pain assessment in 1 of 2 patients receiving Tridil (Patient #28); and

3) administer starting dose of Tridil and Heparin as ordered by the physician (Patient #31).

Findings include:

1) Hospital policy titled "Medication Administration" requires: "Medications may only be administered...pursuant to an order...medication dose...will be documented...Medication Administration Record immediately at the time of administration...Document...Medications not given and reason...."

The facility's sliding scale insulin orders revealed subQ injection, TID (three times per day) 15 minutes before meals. The protocols are as follows:
NPO patients, BMI (body mass index) > (greater than) 30, and BMI < (less than) 25
70-110 0 additional units
111-130 0 additional units
131-150 0 additional units
151-175 1 unit
176-200 2 units
201-225 3 units etc.
Bedtime scale:
same as above except coverage begins as follows:
176-200 1 unit
201-225 2 units etc.

The following patient's medical record revealed an order for sliding scale insulin:

Patient #21 was admitted to the facility on 10/19/11, for Coronary Artery Bypass Graft surgery.

The patient's Medication Administration Record (MAR) dated 10/21/11, at 1128 hours revealed a blood sugar (BS) of 196, there was no documented coverage of insulin given.

Patient #27 was admitted to the facility on 10/22/11, for unstable angina and a history of coronary artery disease.

The patient's MAR revealed the following blood sugars with no documentation of the insulin dosage required:
10/22/11 at 1651 hours, BS 157
10/23/11 at 1307 hours, BS 177
10/24/11 at 1149 hours, BS 193.

Patient # 29's MAR revealed the following blood sugars with no documentation of the insulin dosage required:
07/23/11 at 1152 hours, BS 171
07/23/11 at 1619 hours, BS 176
07/24/11 at 0004 hours, BS 194
07/24/11 at 1654 hours, BS 168
07/24/11 at 1157 hours, BS 184
07/25/11 at 1201 hours, BS 181
07/25/11 at 1630 hours, BS 176
07/26/11 at 1658 hours, BS 181
07/27/11 at 1212 hours, BS 179
07/30/11 at 0808 hours, BS 156
07/31/11 at 0744 hours, BS 152.

The Director of Quality Management, Quality Managers employees #42 and 43, and RN #44, confirmed Patient's #21, 27, and 29 were to have insulin administered to the above sliding scale during an interview conducted on 10/25/11 and 10/26/11.

2) Hospital policy titled "Pain Management" requires "...management of pain is a priority...affects quality of care. Clinicians will assess...rating scales...will document the efficiency of pain relief at regular intervals...."

Patient #28's medical record revealed the patient was admitted 10/24/11, to the Cardiac Progressive Care Unit (CPCU) with chest pain.

The patient was ordered Tridil infusion 50 milligrams (mg), concentration to equal 200 micrograms (mcg) per milliliter (ml). Start infusion at 10 mcg per minute. Titrate every one minute by 10 mcg/min. For relief of ischemic chest pain to a goal of zero out of 10.

Review of the patient's MAR revealed the patient was started on the Tridil infusion on 10/24/11 at 1621 hours, dosage 10 mcg/min. The medication was continued at 10 mcg/min with no increase in the dosage. On 10/26/11, the Tridil was discontinued at 0830 hours.

The patient's pain assessment was documented only once on 10/25/11 at 1235 hours. The pain was documented as anterior chest, quality described as aching and level of intensity documented as 5.

The Quality Specialist and the ICU RN #13 confirmed the patient was not assessed at regular intervals for pain relief during an interview conducted on 10/26/11.

3) The hospital policy titled "Medication Administration" requires: "... Before administrating...licensed caregiver...responsibility to verify...right medication...right dose...for each medication administered...."

Patient #31's medical record revealed the patient was admitted to the facility for right leg ischemia. The patient underwent a thrombolysis catheter placement, thrombectomy of the right tibial artery, and fasciotomy, and a right below-the-knee amputation.

The patient was ordered Tridil infusion 50 milligrams (mg), on 08/26/11 at 1648. Concentration to equal 200 micrograms (mcg) per milliliter (ml). Start infusion at 10 mcg per minute. Titrate every one minute by 10 mcg/min. For relief of ischemic chest pain to a goal of zero out of 10.

Review of the patient's MAR revealed documentation that the patient was started on the Tridil infusion on 08/26/11 at 1715 hours, dosage 15 mcg/min. The medication was discontinued on 08/26/11 at 1900 hours.

Review of the patient's medical record dated 08/23/11 at 1142 hours, revealed an order for Heparin infusion at 900 units/hour, intravenous, 25,000 units in 250 ml D5W (dextrose 5% in water) equals 100 units/ml. Start Heparin at 8 pm tonight. No Initial Bolus.

Review of the patient's MAR dated 08/23/11 at 1824 hours, revealed documentation that the patient received a Heparin bolus dose of 6,160 units.

The Quality Specialist and the ICU RN #13 confirmed the patient received an incorrect starting dosage for the above medications during an interview conducted on 10/26/11.

Based on review of National Fire Protection Association's NFPA 1999 Standards, hospital policies and procedures, facility documentation, and staff interviews, it was determined the facility failed to develop a policy for daily monitoring, maintaining, and documenting the temperature/humidity in the operating rooms located in the surgical suites.

Findings include:

The National Fire Protection Association's NFPA 1999 Standard for Health Care Facilities requires operating rooms to be maintained with a humidity of 35% or greater.

The Association of preoperative Registered Nurses' (AORN) Perioperative Standards and Recommended Practices 2010 Edition, p. 221, V.b. revealed: "...Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC system...V.c.1.Temperature should be maintained between 68 degrees F to 73 degrees F...within the operating room suite and general work areas in sterile processing...."

Hospital policy/procedure titled "Perioperative Services" requires: "...Provide a safe procedural environment...appropriate attention to...temperature and humidity.

Hospital documents labeled "Temperature, humidity, and airflow monitoring" are logs that are completed by the facilities management on a weekly basis. Operating rooms (OR) #1 through #6 were reviewed for the weeks of 09/06/11 through 10/25/11, for a total of 8 weeks.

The following operating rooms were out of recommended range according to NFPA for humidity standards and AORN for temperature standards.

Week of 09/13/11, OR #5 & 6, temperatures recorded as 65.1 & 66.5 degrees F.
Week of 09/20/11, OR #5 & 6, temperatures recorded as 64 & 66 degrees F.
Week of 09/27/11, OR #2, 3, 4, and 6 , temperatures recorded as 66.5, 66.9, 65.9, and 66.7. degrees F.
Week of 10/04/11, OR #2, 3, 5, and 6, temperatures recorded as 67.6, 64.9, 67, 67.2 degrees F.
Week of 10/11/11, OR# 5 & 6 temperatures recorded as 67.7 and 67.9 degrees F;
Week of 10/11/11, OR #1, 2, 3, 4, 5, and 6, humidity recorded as 25.6, 26.3, 26.2, 27.7, 29.5, and 29.9 %
Week of 10/18/11, OR # 2, 3, 4, 5, and 6, temperatures recorded as 66.7, 65.9, 67.9, 67.1, 67.4 degrees F.
Week of 10/18/11, OR # 1, 2, 3, 4, 5, and 6, humidity recorded as 27.8, 29.7, 30.8, 28.7, 29.1, and 29.8 %.
Week of 10/25/11, OR #2, 3, 4, 5, and 6, temperatures recorded as 66.6, 69.8, 66.8, 67.5, 66.1 degrees F.

The Director of Facility Operations, confirmed the hospital keeps a weekly log of the operating rooms temperature and humidity, however, the facility does not have a specific policy to correct these issues.