HospitalInspections.org

Based on record review and staff interview, the Hospital failed to obtain the consent for admission to the hospital from one patient's (#14) legal guardian (LG), failed to allow the LG to make informed decisions regarding the patient's care to include being involved in the patient's care planning and treatment decisions and being able to refuse treatment offered, in a total sample of 31.

Findings include:

Patient #14 was admitted to the emergency room on 11/12/17 and was admitted to the hospital with diagnoses of aspiration pneumonia, and dehydration and had a history of anoxia brain injury, tracheostomy with trach mask and was fed exclusive via a gastrostomy (GT) feeding tube.

Record review indicated the patient resided at a skilled nursing center and the patient's mother had been appointed permanent legal guardian (LG).

Review of the medical record indicated that the "General Consent of Treatment" was blank and there was no indication that the Patient's LG been contacted prior to admission to signed the consent for treatment. Review of the "Acknowledgement of Privacy Rights and Practices and Consent for Communication" was also left blank with the exception of the box labeled "staff use only" where a staff member documented "disabled" and signed and dated 11/12/17 at 6:30 P.M.

On 11/15/17 at 10:13 A.M. the Director of Revenue Cycle was interviewed and said that
when a patient is unable to sign their own consent for admission, then the LG should have been contacted and verbal consent obtained and staff should always have 2 staff to verify that the consent was obtained over the telephone.

27110

Based on observation, records reviewed and interview the Hospital failed to consistently adhere to the policy and standards of care regarding medication handling for one of 31 sampled patients (Pt #10) in the Cardiac Catherization Laboratory and for non-sampled patients in Endoscopy holding area and the Emergency Department.

1.) The policy titled Labeling of Medications, Medication Containers and Solutions, dated April 2016, indicated that medications, medication containers and solution labels will be both verbally and visually verified. Verification is done by two individuals qualified to participate in the procedure whenever the person preparing the medication or solution is not the person who will be administering it.

During an observation in the Cardiac Catherization Laboratory at 11:30 A.M. on 11/13/17 the Surveyor observed Radiology Technician (RT) #1, who was scrubbed in for the case, label four containers on the sterile table that were to receive medications that may be need during the procedure.

Circulating Nurse #1 was observed procuring medications from the automated medication dispenser and then poured the different clear medications into the labeled containers on the sterile field without verifying the medications with RT #1, per hospital policy.

Radiology Technician #1 did not participate in the verbal or visual verification of the medications poured into the containers as required by Hospital policy and procedure.

2.) The Massachusetts Board of Registration in Nursing (Board) Advisory Ruling Number 9204 titled Infusion Therapy, dated May 13, 2015 indicated the nurse was not to administer an infusion solution that the nurse has not procured, removed from the sealed container, and prepared. It is the Board's position that it is not possible to safely verify the contents of a solution that has been removed from its outer, sealed container.

The Surveyor observed Registered Nurse (RN) #3 at 10:30 A.M. on 11/14/17 in the pre-holding area of the Endoscopy Unit. RN #3 said that she was waiting for her patient to change into his Hospital attire and then another RN would initiate the intravenous (IV). RN #3 said that the another RN in the Endoscopy Unit had just spiked the IV solution for her, indicating that RN #3 had not done it herself.

3.) According to USP 797, the national standard for preparation of sterile medications for intravenous or injection, preparation of an immediate-use Compounded Sterile Products (CSP) must only involve "simple transfer of not more than three commercially manufactured ...sterile nonhazardous products from the manufacturer ' s original containers and not more than two entries into any one container or package (e.g. IV bag, vial) of sterile infusion solution or administration container/device." Administration begins not later than one hour following the start of the preparation of the CSP (if not, the CSP must be appropriately discarded). This is to prevent the potential for blood stream infections from IV medications.

The Surveyor toured the Emergency Department on 11/14/17 at 9:00 A.M. and observed in the trauma room two spiked intravenous (IV) solution bags of normal saline that were attached to IV tubing and primed through the IV rapid fluid infuser. The IV solution bags and the IV tubing was not dated, not timed and did not indicate who prepared the solutions that appeared ready for immediate patient use.

Based on record review and interview, the hospital failed to ensure that for one patient, (Patient #9), out of a total sample of 31 patients, the documentation regarding the administration of blood was completed according to Hospital Policy.

Findings include:

According to the Hospital Policy titled Administration of Blood and Blood Products, indicated that the TAR (Transfusion Administration Record) will contain the date and time the transfusion was started, and the time the transfusion was completed. According to the Policy when the transfusion is complete the staff ("Transfusionist") signs the Blood Compatibility sheet and fax's it to the blood bank. If the TAR documentation is electronic, the nurse will click "End" in the TAR (Transfusion Administration Record). Then document the end date/time, total intake and "yes" in the query "Is the transfusion ended?"

Review of Patient #9's TAR, dated 11/9/17 indicated the start time at 9:18 A.M. and the end date and time as 11/10/17 at 9:45 A.M.

According to the policy and the physician's order the blood transfusion was to be completed in 4 hours or less.

Further review indicated that the prior to the completion of the blood transfusion on 11/9/17, the Patient underwent a colonoscopy. The TAR indicated the transfusion was still running on transfer and to be completed there.

During interview on 11/15/17 at 10:45 A.M., with the Clinical Nurse Specialists, she reviewed the documentation. She said that the medical record was a hybrid (paper and electronic). She said the staff providing the colonoscopy did not have access to the electronic record and the nurse transferring the Patient should have ended the transfusion in the electronic record upon transfer of care and documented her reason. She said that although, there was evidence the staff did obtain a form for completion of the transfusion the information was not identified on the TAR.

Based on records reviewed and interviews the Hospital failed to maintain an accurate medical record for four patients ( #3, #4, #10 and #28), in a total sample of 31 patients. Findings include:

1.) Review of the medical record for Patient #3, dated 11/13/17, indicated that the patient underwent an invasive procedure that required informed consent. The informed consent was signed by the Proceduralist in the space provided for the patient's signature and not in the space provided for the Proceduralist. The informed consent was dated with the month and year as 11/17, however the day was not documented.

Patient #3's Physician Order sheet indicated a previous Hospital owner's name. The Hospital was sold six years prior to survey.

Patient #3 also received a new gastrostomy feeding tube from a Gastroenterologist on 11/14/17. The Gastroenterologist documented that the tube feeding formula was to begin at 140 ml (milliliters) per hour. However, the Physician Order Sheet indicated the physician ordered a rate of 40 ml per hour.

2.) Patient #4 had an admitting diagnosis of chest pain and morbid obesity. Patient #4's record, dated 11/13/17, indicated a body mass index (BMI) listed at 21.87. According to the Center for Disease Control (CDC) a BMI exceeding 30 indicates obesity. Patient #4's medical record was further reviewed and the entry of 152 was mistakenly entered as pounds instead of kilograms which yielded a BMI of 48.

3.) Patient #10 was medical record indicated a report from the Cardiac Catherization Laboratory. Patient #10's date of birth on the left side was recorded as xx/xx/1962. Patient #10's date of birth was listed on the right hand side as xx/xx/1958.


4.) Patient #28's post anesthesia record, dated 11/13/17, was signed with an illegible signature that could not be authenticated resulting in the author of the entry not being identifiable.

Based on record review, observation and staff interview, the hospital failed to have the practitioner responsible for the care of the patient order a therapeutic diet for 1 patient (#6), in a total sample of 31, whose medical diagnoses indicated the need for a therapeutic diet, including a consistency change.

Findings included:

Patient #6 was admitted to the hospital on 11/12/17 with a Cerebral Vascular Accident (CVA). The patient also had a history of high cholesterol, GERD ( gastroesophageal reflux disease), and dementia.

On 11/14/17 the patient's medical record was reviewed and indicated that the patient was on a "Cardiac" therapeutic diet.

Review of the Dietitian's nutritional assessment, dated 11/13/17 at 6:51 A.M., indicated that the patient lived at a skilled nursing center and received a No Added Salt (no orange juice or banana) diet. The dietitian also documented on the assessment that the patient was at nutrition risk due to a 50% intake at meals, not oriented per nursing documentation and had an increased risk for skin breakdown. The documented plan was to continue with the Cardiac diet and add Ensure Hi Protein at breakfast, Ensure pudding twice a day, monitor labs and await SLP (Speech and Language Pathologist) recommendations.

Further review of the medical record indicated that on 11/13/17 at 11:29 A.M. the SLP conducted a bedside swallow evaluation for Patient #6. The SLP recommended that the patient receive a Dysphagia Advanced (soft solids) diet with thin liquids and alter solids and liquids to clear oral residual. The goal identified by the SLP was for the patient to manage without any signs and symptoms of aspiration in order to optimize safety and promote nutrition and hydration.

On 11/14/17 at 12:30 P.M. the Surveyor reviewed the case with the Chief Clinical Dietitian. The medical record was reviewed and indicated that the patient's diet had not been changed to the recommended consistency per the SLP. The Surveyor and the facility Dietitian visited the patient and verified that the diet consistency had not been changed.

At 2:00 P.M. the surveyor again reviewed the medical record of Patient #6 and saw that the diet had been change to Dysphagia advances with Ensure Hi Protein. The Cardiac Therapeutic diet had been removed.

On 11/14/17 at 2:15 P.M. the Dietitian contacted the Director of SLP via telephone for the Surveyor. The Director put the phone on speaker and identified that the SLP who evaluated Patient #6 was also present. The Director identified what the current system was to "upgrade" a diet consistency and explained that the SLP would communicate the recommendation to the nurse, who would then contact the physician and obtain the order. It would be up to the SLP to follow up the next meal and verify that the diet order (consistency change) had been completed. The Director said that the SLP had obtained the order changed to Dysphagia Advanced that day after having a conversation with the Dietitian, however the Cardiac Therapeutic diet was not visible in the physician's orders. The Director said that they were not aware of how to maintain a therapeutic diet in the orders when there is a consistency change. The Director said that this has been an ongoing problem in obtaining timely consistency changes for patients.

Based on observation, records reviewed and interviews the Hospital failed to consistently adhere to Infection Prevention standard in High Level Disinfection and employee fit testing. Findings include:

1.) High level disinfection (HLD) is a process that removes most viable microorganisms on medical equipment that is reprocessed between patients.

The Surveyor toured the reprocessing room in the Endoscopy Unit at 10:45 A.M. on 11/14/17 and interviewed Endoscopy Technician (ET) #1.

Endoscopy Technician #1 said she used the chemical reservoir located within the automated endoscopic reprocessor (AER) to manually high level disinfect the Manometry Probe (a piece of equipment used to monitor gastric mobility) between patients.

According to the manufacturer's directions for use (mdfu) no items are to be disinfected using the chemical reservoir.

ET #1 said after submerging the probe in the chemical reservoir she rinsed the probe in running water in the sink. ET #1 indicated she used the hand washing sink in the reprocessing room. The hand washing sink is to be used for handwashing alone and it is not to be used as a utility sink for activities such as equipment rinsing.

Endoscopy Technician #1 said she would rinse the probe under the running water for three minutes. According to the manufacturer's direction for use, the correct manual rinsing procedure to remove all residual high level disinfectant it to immerse the instrument totally for a minimum of one minute in a large volume of water. The immersion rinses are repeated twice more using fresh volumes of water.

2.) According to the Centers for Disease Control (CDC), the The Occupational Safety and Health Administration (OSHA) and the Hospital's policy entitled "Respiratory Protection Program", mandatory compliance for annual respiratory mask fit testing for airborne transmissible diseases is required.

The Surveyor interviewed Physician #1 at 8:00 A.M. on 11/13/17. Physician #1 said he was a Pulmonologist (a specialist in Respiratory diseases) and a Bronchoscopist (a practitioner who performs bronchoscopies, a procedure to look inside the lungs).

Physician #1 said he would don an N95 during a bronchoscopy that was deemed high risk for tuberculosis.

Physician #1's employee health record indicated that fit testing had not been completed since 2010.