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Based on medical record review, patient interview, and staff interview, the facility failed to ensure Patient 7 and Patient 8 were given their patient rights. This affected 2 of 45 medical records reviewed. The facility census was 77.

Findings include:

The medical record review for Patient 7 was completed on 06/13/12. The medical record review revealed the 36 year old patient presented to the emergency department on 06/13/12 at 6:17 AM with a chief complaint of trouble swallowing and body aches that started two days ago. On 06/13/12 at 8:30 AM, the surveyor and Staff A interviewed the patient. The patient stated he/she did not have patient rights, and would like to have them.

The medical record review for Patient 8 was completed on 06/13/12. The medical record review revealed the 26 year old patient presented to the emergency department at 6:41 AM with a chief complaint of back pain. On 06/13/12 at 8:45 AM, the surveyor and Staff B interviewed the patient. The patient stated he/she did not have patient rights, and would like to have them.

There were seven patients being attended to in the emergency department when Patient 7 and Patient 8 were interviewed.

Based on interview and medical record review, the facility failed to ensure Patient 10's response prior to, during, and after cardiac medication, was documented and supported with cardiac rhythm strips.This affected one of 45 medical records reviewed. In addition, observation, staff interview, and policy review revealed the facility failed to ensure staff providing wound care to Patient 45 followed facility policy and procedure for hand hygiene. This affected one of two patients observed receiving wound care. The facility had a census of 77 patients.

Findings include:

The medical record for Patient 10 was presented in electronic and paper form for review and completed on 06/13/12. The paper medical record review revealed the 77 year old patient presented to the emergency department on 06/12/12 at 12:49 PM with a chief complaint of dizziness, possible syncopal episode. This review revealed a nursing note dated 06/12/12 at 1:30 PM that stated the patient had new atrial fibrillation and had "been feeling dizzy and flushed x 3 days denies any chest pain - rates 90 - 160 ...". The note stated he/she had been dizzy prior to Sunday, 06/10/12, and on 06/10/12 the dizziness was worse. The note said the patient couldn't get out of the chair then, and on 06/13/12 he/she passed out while in his/her home office. The review revealed a physician's order dated 06/12/12 at 2:00 PM to place the patient on a cardiac monitor.

The medical record review in both its electronic and paper form did not reveal a cardiac rhythm strip and/or an interpretation of the patient's cardiac rhythm when the diltiazem drip was begun at 2:32 PM, stopped at 2:42 PM, and in the time between 2:42 PM and 3:45 PM when the patient was interpreted to be in normal sinus rhythm.

The medical record failed to reveal where the patient's cardiac rhythm was interpreted by the nurse, or where a rhythm strip was mounted to the chart on 06/12/12 at 2:14 PM, or in the time between 06/12/12 at 2:00 PM (when cardiac monitoring was ordered) and 06/12/12 at 2:14 PM.

The paper medical record revealed a nursing note dated 06/12/12 at 2:14 PM that stated the patient's heart rate would go between 90 and 190 beats per minute and when the rate was high the patient was dizzy. The paper medical record revealed a physician's order dated 06/12/12 at 2:22 PM to give the patient diltiazem 10 milligrams by injection. The electronic medical record revealed on 06/12/12 at 2:22 PM the drug was given and the patient's heart rate was 187 beats per minute with a blood pressure of 76 millimeters mercury/ 52 millimeters mercury. Neither form of the record revealed a rhythm strip to demonstrate what the patient's heart rhythm was prior to and shortly after receiving the diltiazem. The medical record review in its electronic form revealed a nursing note dated 06/12/12 at 2:32 PM that stated the patient became dizzy and his/her heart rate increased to 180 beats per minute. The note did not indicate what the patient's cardiac rhythm was, and the clinical record in both its electronic and paper form did not reveal a cardiac rhythm strip to demonstrate what the rhythm was.

The medical record review in paper form revealed a physician's order dated 06/12/12 at 2:32 PM to begin a diltiazem drip at 10 milligrams/hour. The electronic medical record revealed a nursing note that stated on 06/12/12 at 2:32 PM the drip was started. The paper medical record review revealed a physician's order dated 06/12/12 at 2:42 PM to stop the diltiazem drip. The electronic record review revealed a nursing note dated 06/12/12 at 2:42 PM that stated the drip was stopped and at 3:00 PM the patient's heart rate was 98 beats per minute and at 3:45 PM the patient's heart rate was 83 beats per minute in normal sinus rhythm.

On 06/13/12 at 1:58 PM, in an interview, Staff A confirmed the absence of an interpretation of the cardiac rhythm between 2:32 PM when the diltiazem drip was begun and 2:42 PM when the diltiazem was stopped. He/she said the facility did not have a policy that required the nursing staff to document a cardiac rhythm strip.

On 06/13/12 at 3:00 PM in an interview, Staff A confirmed even when the monitor sounds a cardiac rhythm alarm, the nurse is not required by policy to post a rhythm strip. He/she said even if the patient developed a third degree heart block or supraventricular tachycardia, a strip would not necessarily be required to be mounted-unless they became life threatening. He/she then said if a code blue was called, all strips would then need to be recorded into the medical record.





29377

On 6/13/12 beginning at 3:20 PM, observations of Staff F, performing wound care on Patient 45 were made. Prior to initiating care, Staff F was observed to wash his/her hands and put on a pair of clean gloves. Staff F proceeded to remove the ace wraps and kerlex wrap from Patient 45's left leg. Staff F then removed and disposed of his/her dirty gloves in a red biohazard bag and applied a clean pair without performing hand hygiene. Staff F then grabbed a bottle of sterile water and began to pour it over the remaining dressings on Patient 45's left leg in order to help loosen it from the skin. Staff F then proceeded to remove and dispose of those dressings, remove his/her dirty gloves and apply a clean pair of gloves. No hand hygiene was performed between glove changes. Staff F began to wipe down Patient 45's left lower leg with a wet paper towel and then applied lotion to the leg. He/she again changed gloves without performing hand hygiene in between. Staff F then grabbed 2x2 gauze pads and started to wipe off the excess lotion from Patient 45's skin. Staff F changed gloves again without performing hand hygiene in between. Staff F then gathered gauze soaked in sterile water and proceeded to wipe down the blisters and reddened areas on Patient 45's left lower leg and then applied non-adherent dressings. Staff F changed gloves again without performing hand hygiene in between. Staff F then applied additional non-adherent dressings to the patient's wound and then Neosporin ointment. Staff F changed gloves again without performing hand hygiene in between. Staff F proceeded to apply additional non-adherent dressings, cover with ABD pads, and then wrap the left lower leg with kerlex and ace wraps. Staff F changed gloves again without performing hand hygiene in between and then used silk tape to secure the ace wraps. Staff F had completed wound care on the left leg. Staff F continued this same pattern while performing wound care on Patient 45's right lower leg. Staff F was observed to change his/her gloves four additional times without performing hand hygiene in between.

Staff F was interviewed on 06/13/12 at 4:43 PM and made aware of the above findings. At that time he/she confirmed hand hygiene had not been performed between the above noted glove changes but that it should have been.

Review of facility policy IC0002, Hand Washing, revealed staff are to wash hands after removing gloves. The policy further stated "gloves do not replace hand hygiene" and "gloves must be decontaminated after removing gloves."

Based on observation and staff interview, the facility failed to ensure contracted employees were aware of the procedure for responding to medical and/or non medical emergencies. This affected one of one contracted employees observed.

Findings include:

On 06/13/13, beginning at 9:30 AM, a tour of the facility's inpatient dialysis rooms was conducted. During that time, interview and observation of Staff E was also made. Staff E was asked to explain how he/she would respond to an emergency situation, either medical or non-medical. At that time, Staff stated he/she would "probably use the call button if there was one" and then attempted to locate the call button. When Staff E was unable to locate a call button, he/she stated if there was no call button he/she would then "call out into the hall for the two south nurses." The dialysis room was located at end of the hallway. Staff E was unable to recall any education he/she had received regarding how to respond to emergency situations.

Staff D was also present during the above encounter and stated Staff D should use the telephone to dial 1-2-3-4. Review of Staff E's file revealed Staff E had attended training on 9/11/11 which included using telephone to dial 1-2-3-4.

Based on interview and medical record review, the facility failed to ensure each patient received intravenous fluids and oxygen in accordance with physician's orders. This affected 2 of 45 medical records reviewed (Patients 4 and 22). The facility census was 77.

Findings include:

The medical record review in its electronic and paper form for Patient 4 was completed on 06/13/12. The medical record review revealed the 86-year-old patient arrived to the emergency department on 06/12/12 at 12:22 PM by squad for vomiting of coffee ground emesis. The medical record review in its electronic form revealed on 06/12/12 at 1:00 PM the patient had 500 milliliters of coffee ground emesis. The paper medical record review revealed a nursing note dated 06/12/12 at 2:45 PM that stated the patient was receiving 500 milliliters of normal saline through an intravenous access in the right hand. The paper medical record revealed a nursing note dated 06/12/12 at 3:30 PM that stated the patient was receiving 500 milliliters of normal saline through intravenous access in the left hand. The medical record review, in both its electronic and paper form, lacked any physician's order for normal saline to be infused at 500 milliliters an hour.

On 06/13/12 at 11:26 AM in an interview, Staff A confirmed the patient had received intravenous fluids at a rate of 500 milliliters into each hand and there wasn't an order to do so.



31597


The medical record review for Patient 22 was completed on 06/14/12. The medical record review revealed the patient was admitted to the hospital on 05/16/12 with a diagnosis of right stomach pain and right loin pain. Medical record review revealed the nurse administered two liters of oxygen to the patient at 11:00 PM on 05/17/12. The nurse documented the patient's oxygen saturation as " 97% on room air " and " leaving oxygen on for comfort." The medical record did not have a physician's order for oxygen administration.
On 06/14/12 at 2:17 PM Staff H was interviewed and the findings were shared with no dispute to the findings.

Based on medical record review and staff interview the facility failed to ensure orders for x-ray services were completed within the required timeframe. This affected one of one patient medical record reviewed with orders for STAT x-ray services, Patient 26. The current census was 77.

Findings include:

The medical record for Patient 26 was reviewed on 06/13/12 and revealed he/she arrived to the emergency department on 06/11/12 with complaints of slurred speech, weakness and mental confusion. After determining the patient's onset of stoke symptoms were outside of the 8 hour window, the facility initiated the Stroke Protocol for Patient 26 which includes STAT CT scan.

Further review revealed a STAT CT scan of the brain without contrast was ordered for Patient 26 on 06/11/12 at 3:18 PM. According to the medical record, Patient 26 had the CT exam done on 06/11/12 at 5:08 PM, one hour and 50 minutes after the order was placed.

On 06/13/12 at 4:55 PM, Staff G (facility stroke coordinator) was interviewed regarding STAT CT scan orders and stated that according to the Director of Radiology there is no policy related to STAT CT scan orders and how quickly they must be completed. The Director of Radiology stated that STAT moves the ordered test to the top of the work list. Radiology then has 30 minutes to interpret the test after it is completed. Staff G then confirmed the CT scan for Patient 26 was interpreted 39 minutes after it was completed.

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure STAT orders for laboratory services were completed within the required timeframe. This affected one of one patient, Patient 26, whose medical record was reviewed with STAT laboratory orders. The current census was 77.

Findings include:

The medical record for Patient 26 was reviewed on 06/13/12 and revealed he/she arrived to the emergency department on 06/11/12 with complaints of slurred speech, weakness and mental confusion. After determining the patient's onset of stroke symptoms were outside of the 8 hour window, the facility initiated the Stroke Protocol for Patient 26.

STAT orders for the following labs were entered on 06/11/12 at 3:18 PM: complete metabolic panel, troponin T, CK total and CK-MB and complete blood count with differential. Further review of the record revealed all of the above labs were collected on 06/11/12 at 4:08 PM, 50 minutes after the initial order.

Staff I, the Director of Quality was interviewed on 06/13/12 at 11:35 AM and asked what the expectation for turnaround time on a STAT order was. Staff I stated he/she believed it was one hour but he/she was uncertain and was also not aware of any facility policy regarding STAT orders.

At 11:40 AM, Staff I returned and presented a lab policy electronically to the surveyor specific to laboratory services that revealed all STAT order for labs are to be drawn within 30 minutes and results recorded within one hour of receipt of the order.

The medical record for Patient 26 was further reviewed and revealed the following:

1) Final lab result for comprehensive metabolic panel reported at 4:53 PM, one hour and 35 minutes after the order.

2) Final lab result for troponin T reported at 4:55 PM, one hour and 37 minutes after the order.

3) Final lab result for CK total and CK-MB reported at 4:57 PM, one hour and 39 minutes after the hour.

4) Final lab result for complete blood count with differential reported at 6:27 PM, three hours and nine minutes after the order.

All of the above findings were reviewed with and confirmed by Staff G on 06/13/12 at 4:48 PM.

Based on interview and observation, the facility failed to ensure stairwell doors, exit directional signs, smoke barriers, sprinkler pendants, fire extinguishers, smoke detectors, storage of linen carts, battery operated lights met the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all 145 patients in the facility.

Findings include:

See A710.

Based on observation, interview, and policy review, the hospital failed to provide a clean and sanitary environment in both the kitchen area and in operating room #6. These deficient practices affected 74 of 74 patients and all who were served food from the kitchen on 06/13/12 and seven of seven patients who had procedures performed in operating room #6 during the time of the survey (06/12/12 through 06/14/12). The total census at the time of the survey was 77 patients.

Findings include:

On 06/13/12 during an environmental tour of the kitchen from 8:00 AM to 9:15 AM, an observation was made of a stainless steel hood unit located above a gas stove, where there were two sets of fire suppression sprinklers. One set consisted of two non-functioning sprinkler heads and the other set consisted of two red-capped fire suppression nozzles. All four apparatuses were visibly coated with an accumulation of grease and dust. This finding was verified with both Staff AA and Staff BB 06/14/12 at 8:00 AM.

On 06/13/12 at 10:36 AM observation in operating room #6 revealed a square stainless steel boom (a power unit which drops down from the ceiling and has a row of electrical outlets on the outside and air, oxygen, vacuum and power sources coming down from the middle). The sloped rim covering the boom had a visible layer of dust. This finding was verified with Staff B and Staff C 06/13/12 at 10:40 AM.

On 06/14/12 at 2:30 PM review of the hospital policy entitled Cleaning and Sanitation with a last review date of January 2011, revealed the section entitled Nonfood Contact Surfaces stated, " Nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris." On 06/14/12 at 2:30 PM review of the hospital policy entitled Area and Equipment Cleaning Schedules and Frequency with a last review date of January 2011 failed to address the cleaning of the stainless steel hood or the fire sprinkler above the gas stove.

On 06/14/12 at 2:30 PM review of the hospital policy entitled Environmental Cleaning Surgical Areas with a last review date of 10/08/10 revealed the section titled Preparation of the operating room stated, " Visual inspection, of the operating room, for cleanliness before case carts, supplies, equipment, and instruments are brought into the room. All horizontal surfaces, in the operating room (e.g., furniture, surgical lights, booms, equipment) will be damp dusted before the first scheduled surgical procedure of the day. " The section titled End of day cleaning and terminal cleaning stated, " Ceiling and wall mounted fixtures and tracks will be cleaned on all surfaces. "

Based on observation, record review, and interview, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all 77 patients in the facility.

Findings include:
Please see the Life Safety Code report for the details: K 20 (door in stairwell failed to latch shut), K 22 (lacked exit directional signs), K 25 (penetrations in smoke barriers), K 38 (15 second delay door did not disengage until 30 seconds), K 62 (sprinkler pendants coated with dust and debris, missing escutcheon rings and covers), K 64 (fire extinguishers not mounted properly and access to fire extinguishers blocked), K 75 (mobile linen cart not stored in hazardous area), and K 130 (smoke detectors sensitivity testing not performed, battery operated lights not tested for 30 seconds monthly and not tested annually, sprinkler system not tested quarterly, and no monthly fire extinguisher inspections).

Based on interview and medical record review, the facility failed to ensure Patient 10's response prior to, during, and after cardiac medication, was documented and supported with cardiac rhythm strips.This affected one of 45 medical records reviewed. In addition, observation, staff interview, and policy review revealed the facility failed to ensure staff providing wound care to Patient 45 followed facility policy and procedure for hand hygiene. This affected one of two patients observed receiving wound care. The facility had a census of 77 patients.

Findings include:

The medical record for Patient 10 was presented in electronic and paper form for review and completed on 06/13/12. The paper medical record review revealed the 77 year old patient presented to the emergency department on 06/12/12 at 12:49 PM with a chief complaint of dizziness, possible syncopal episode. This review revealed a nursing note dated 06/12/12 at 1:30 PM that stated the patient had new atrial fibrillation and had "been feeling dizzy and flushed x 3 days denies any chest pain - rates 90 - 160 ...". The note stated he/she had been dizzy prior to Sunday, 06/10/12, and on 06/10/12 the dizziness was worse. The note said the patient couldn't get out of the chair then, and on 06/13/12 he/she passed out while in his/her home office. The review revealed a physician's order dated 06/12/12 at 2:00 PM to place the patient on a cardiac monitor.

The medical record review in both its electronic and paper form did not reveal a cardiac rhythm strip and/or an interpretation of the patient's cardiac rhythm when the diltiazem drip was begun at 2:32 PM, stopped at 2:42 PM, and in the time between 2:42 PM and 3:45 PM when the patient was interpreted to be in normal sinus rhythm.

The medical record failed to reveal where the patient's cardiac rhythm was interpreted by the nurse, or where a rhythm strip was mounted to the chart on 06/12/12 at 2:14 PM, or in the time between 06/12/12 at 2:00 PM (when cardiac monitoring was ordered) and 06/12/12 at 2:14 PM.

The paper medical record revealed a nursing note dated 06/12/12 at 2:14 PM that stated the patient's heart rate would go between 90 and 190 beats per minute and when the rate was high the patient was dizzy. The paper medical record revealed a physician's order dated 06/12/12 at 2:22 PM to give the patient diltiazem 10 milligrams by injection. The electronic medical record revealed on 06/12/12 at 2:22 PM the drug was given and the patient's heart rate was 187 beats per minute with a blood pressure of 76 millimeters mercury/ 52 millimeters mercury. Neither form of the record revealed a rhythm strip to demonstrate what the patient's heart rhythm was prior to and shortly after receiving the diltiazem. The medical record review in its electronic form revealed a nursing note dated 06/12/12 at 2:32 PM that stated the patient became dizzy and his/her heart rate increased to 180 beats per minute. The note did not indicate what the patient's cardiac rhythm was, and the clinical record in both its electronic and paper form did not reveal a cardiac rhythm strip to demonstrate what the rhythm was.

The medical record review in paper form revealed a physician's order dated 06/12/12 at 2:32 PM to begin a diltiazem drip at 10 milligrams/hour. The electronic medical record revealed a nursing note that stated on 06/12/12 at 2:32 PM the drip was started. The paper medical record review revealed a physician's order dated 06/12/12 at 2:42 PM to stop the diltiazem drip. The electronic record review revealed a nursing note dated 06/12/12 at 2:42 PM that stated the drip was stopped and at 3:00 PM the patient's heart rate was 98 beats per minute and at 3:45 PM the patient's heart rate was 83 beats per minute in normal sinus rhythm.

On 06/13/12 at 1:58 PM, in an interview, Staff A confirmed the absence of an interpretation of the cardiac rhythm between 2:32 PM when the diltiazem drip was begun and 2:42 PM when the diltiazem was stopped. He/she said the facility did not have a policy that required the nursing staff to document a cardiac rhythm strip.

On 06/13/12 at 3:00 PM in an interview, Staff A confirmed even when the monitor sounds a cardiac rhythm alarm, the nurse is not required by policy to post a rhythm strip. He/she said even if the patient developed a third degree heart block or supraventricular tachycardia, a strip would not necessarily be required to be mounted-unless they became life threatening. He/she then said if a code blue was called, all strips would then need to be recorded into the medical record.





29377

On 6/13/12 beginning at 3:20 PM, observations of Staff F, performing wound care on Patient 45 were made. Prior to initiating care, Staff F was observed to wash his/her hands and put on a pair of clean gloves. Staff F proceeded to remove the ace wraps and kerlex wrap from Patient 45's left leg. Staff F then removed and disposed of his/her dirty gloves in a red biohazard bag and applied a clean pair without performing hand hygiene. Staff F then grabbed a bottle of sterile water and began to pour it over the remaining dressings on Patient 45's left leg in order to help loosen it from the skin. Staff F then proceeded to remove and dispose of those dressings, remove his/her dirty gloves and apply a clean pair of gloves. No hand hygiene was performed between glove changes. Staff F began to wipe down Patient 45's left lower leg with a wet paper towel and then applied lotion to the leg. He/she again changed gloves without performing hand hygiene in between. Staff F then grabbed 2x2 gauze pads and started to wipe off the excess lotion from Patient 45's skin. Staff F changed gloves again without performing hand hygiene in between. Staff F then gathered gauze soaked in sterile water and proceeded to wipe down the blisters and reddened areas on Patient 45's left lower leg and then applied non-adherent dressings. Staff F changed gloves again without performing hand hygiene in between. Staff F then applied additional non-adherent dressings to the patient's wound and then Neosporin ointment. Staff F changed gloves again without performing hand hygiene in between. Staff F proceeded to apply additional non-adherent dressings, cover with ABD pads, and then wrap the left lower leg with kerlex and ace wraps. Staff F changed gloves again without performing hand hygiene in between and then used silk tape to secure the ace wraps. Staff F had completed wound care on the left leg. Staff F continued this same pattern while performing wound care on Patient 45's right lower leg. Staff F was observed to change his/her gloves four additional times without performing hand hygiene in between.

Staff F was interviewed on 06/13/12 at 4:43 PM and made aware of the above findings. At that time he/she confirmed hand hygiene had not been performed between the above noted glove changes but that it should have been.

Review of facility policy IC0002, Hand Washing, revealed staff are to wash hands after removing gloves. The policy further stated "gloves do not replace hand hygiene" and "gloves must be decontaminated after removing gloves."

Based on interview and medical record review, the facility failed to ensure each patient received intravenous fluids and oxygen in accordance with physician's orders. This affected 2 of 45 medical records reviewed (Patients 4 and 22). The facility census was 77.

Findings include:

The medical record review in its electronic and paper form for Patient 4 was completed on 06/13/12. The medical record review revealed the 86-year-old patient arrived to the emergency department on 06/12/12 at 12:22 PM by squad for vomiting of coffee ground emesis. The medical record review in its electronic form revealed on 06/12/12 at 1:00 PM the patient had 500 milliliters of coffee ground emesis. The paper medical record review revealed a nursing note dated 06/12/12 at 2:45 PM that stated the patient was receiving 500 milliliters of normal saline through an intravenous access in the right hand. The paper medical record revealed a nursing note dated 06/12/12 at 3:30 PM that stated the patient was receiving 500 milliliters of normal saline through intravenous access in the left hand. The medical record review, in both its electronic and paper form, lacked any physician's order for normal saline to be infused at 500 milliliters an hour.

On 06/13/12 at 11:26 AM in an interview, Staff A confirmed the patient had received intravenous fluids at a rate of 500 milliliters into each hand and there wasn't an order to do so.



31597


The medical record review for Patient 22 was completed on 06/14/12. The medical record review revealed the patient was admitted to the hospital on 05/16/12 with a diagnosis of right stomach pain and right loin pain. Medical record review revealed the nurse administered two liters of oxygen to the patient at 11:00 PM on 05/17/12. The nurse documented the patient's oxygen saturation as " 97% on room air " and " leaving oxygen on for comfort." The medical record did not have a physician's order for oxygen administration.
On 06/14/12 at 2:17 PM Staff H was interviewed and the findings were shared with no dispute to the findings.