HospitalInspections.org

Based on document review, and interview, it was determined that for 1 of 2 patients (Pt. #16) reviewed for restraints, the Hospital failed to ensure that a face-to-face assessment by a Physician or Nurse Practitioner was conducted within one (1) hour of the application of behavioral restraints.

Findings include:

1. The Hospital's policy titled, "Restraints Protective Devices & Seclusion," revised by the Hospital 3/2020, was reviewed on 12/14/2020. The policy required, "B. Behavior Restraint: 6. Within one hour of initial application, a behavioral restraint safety huddle will occur to assess the patient's response to the intervention as well as evaluate potential factors contributing to the violent or self-destructive behavior."

2. On 12/14/2020, Pt. #16's clinical record was reviewed. Pt. #16 was admitted on 9/4/2020 with a diagnosis of rule out new seizure.The physician's order, dated 9/4/2020 at 11:29 AM, included an order for behavioral restraints. The restraint flowsheet, dated 9/4/2020 at 11:29 AM, included, "Behavior requiring restraints/seclusion: violent behavior, harm to self , harm to others, banging head and combative." The restraint flowsheet showed that Pt. #16's restraints were initiated at 11:29 AM and discontinued on 9/4/2020 at 12:14 PM. The clinical record lacked documentation that a face-to-face assessment by a Physician or Nurse Practitioner was conducted within one hour of the application of behavioral restraints.

3. On 12/16/2020 at 2:06 PM, an interview was conducted with the Chief Nursing Officer (E #15). E #15 stated that a patient who has behavioral restraints should have a face-to-face assessment by a Licensed Independent Practitioner (Physician or Nurse Practitioner) within 1 hour of being placed in behavioral restraints.

Based on document review and interview, it was determined that for 1 of 8 (Pt. #15) clinical records reviewed for pain assessment/reassessment, the Hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the nursing care of each patient, to ensure that the patient was re-assessed, as required, after receiving pain medication.

Findings include:

1. The Hospital's policy titled, "Pain Assessment & Management" revised by the Hospital 6/2020, was reviewed on 12/15/2020. The policy required, "B. Management/Intervention: 4. For hospital-based patients, reassess pain within 1 hour of intervention."

2. On 12/14/2020, Pt. #15's clinical record was reviewed. Pt. #15 was admitted on 12/12/2020 with diagnoses of congestive heart failure and respiratory failure. The physician's order, dated 12/12/2020, included an order for fentanyl (pain medication) 25 mcg (micrograms) IV (intravenous) push Q15M (every 15 minutes) PRN (as needed) for severe pain. The electronic medication administration record (eMAR) included documentation that Pt. #15 received Fentanyl 25 mcg for pain on 12/13/2020 at 12:29 PM. The clinical record lacked documentation of a pain re-assessment within 1 hour after pain medication administration.

3. On 12/14/2020 at approximately 12:37 PM, an interview was conducted with a RN Clinical Leader (E #12). E#12 stated that the RN must re-assess the patient within 1 hour of administering pain medication. E #12 stated that the re-assessment should be performed to assess the effectiveness of the pain medication and was not performed for Pt. #15.

Based on document review, observation, and interview it was determined that the Hospital failed to manage dietary services by not ensuring that foods were labeled with a use-by date after opening and discarded if past the manufacturer's use-by date. This had the potential to affect all 58 patients receiving oral diets on 12/15/2020.

Findings include:

1. The Hospital's policy titled, "Food Handling Standards and Procedures" (dated 7/5/2019), was reviewed on 12/16/2020 and required, "...Discard foods that are not used by the manufacturer's 'Use By/Best Before" date... foods must be labeled for safety after opening..."

2. During a tour of Dietary Services on 12/15/2020, between approximately 11:00 AM and 12:30 PM, the following was observed:
- The bakery area contained 1 opened container of vanilla icing, labeled with an open date of 10/31/2020. The container was on the counter at room temperature and the manufacturer's label on the container required, "...Once icing container has been opened, the icing can be stored covered at room temperature for one week..."
- The bakery counter also contained 1 container of fondant with a manufacturer's use-by-date of 12/8/2020 and 1 container of opened cream cheese frosting that was not labeled with the date opened.
- The walk-in freezer contained 3 opened bags of cookie dough and 1 opened bag of okra that were not labeled with the date opened.

3. An interview was conducted with the Director of Food & Nutrition Services (E#9) on 12/15/2020 at approximately 11:45 AM. E#9 stated that the icing was kept at room temperature since it was opened on 10/31/2020 and should have been discarded after one week per the manufacturer's instructions. E#9 stated that food items should be discarded if past the manufacturer's use-by-date. E#9 stated that all opened food items should be labeled with the open date to determine when the items need to be discarded.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Recertification Survey conducted on December 15-17, 2020, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Recertification Survey conducted on December 15-17, 2020, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review, observation, and interview, it was determined that for 6 of 13 crash carts and 1 of 1 malignant hyperthermia (severe reaction to certain anesthesia drugs) cart observed, the Hospital failed to ensure that emergency carts were checked routinely as required by policy in order to maintain an acceptable level of safety and quality. This potentially affected the average 150 patients on the daily hospital census.

Findings include:

1. The Hospital's policy titled, "Code Blue Plan" (dated 1/22/2020), was reviewed on 12/15/2020 and required, "...Crash Cart Supply Replacement Process: a. All outdated medications are replaced based on expiration dates by Pharmacy. b. Tracking of drug expiration dates will proactively be provided by pharmacy on a monthly basis... Routine Crash Cart Checks: Crash Cart locks are checked daily when unit is open and documented on the corresponding form... Oxygen and defibrillators are checked daily to ensure adequate supply and battery and documented on the corresponding form... Medications and supplies are checked weekly and documented on the corresponding form by a unit staff member..."

2. On 12/14/2020, a tour of the Hospital units noted the following:

-3 East Medical-Surgical Unit on 12/14/2020 at 10:00 AM- the crash cart inspection log from 12/1/2020-12/14/2020 was reviewed and lacked documentation of daily checks on 12/3/2020; 12/6/2020; and 12/10/2020.

- 2 North Medical-Surgical Unit on 12/14/2020 at 12:00 PM - the crash cart inspection logs from 12/1/2020-12/14/2020 were reviewed and lacked documentation of daily checks on the following dates:
- Adult Crash Cart: 12/2/2020-12/7/2020; 12/9/2020; and 12/11/2020-12/13/2020.
- Pediatric Crash Cart: 12/1/2020; 12/2/2020; 12/4/2020-12/9/2020; and 12/11/2020-12/13/2020.

- Surgical Department (OR) on 12/16/2020, at approximately 10:00 AM -the crash cart and MH cart inspection logs from 12/1/2020-12/16/2020 were reviewed and lacked documentation of weekly medication/supply checks for the Adult and Pediatric Crash Carts and the MH cart located in the Anesthesia Work Room. The MH cart contained the following outdated medications:
- Two of 8 boxes (6 vials per box) of dantrolene (muscle relaxant) had an expiration date of 10/2020.
- One of 2 vials of heparin (blood thinner) had an expiration date of 9/2020.
- One of 1 vial of sodium bicarbonate (antacid) had an expiration date of 8/2020.
- One of 1 vial of furosemide (diuretic - used to reduce body fluid) had an expiration date of 8/1/2020.
- One of 1 vial of naloxone (used to treat opioid overdose) had an expiration date of 9/2020.

- GI (Gastrointestinal) Lab on 12/16/2020, at approximately 11:00 AM - the crash cart inspection logs from 11/1/2020-12/16/2020 were reviewed and lacked documentation of daily checks on the following dates of operation: 11/9/2020-11/11/2020; 11/16/2020-11/19/2020; 11/23/2020-11/25/2020; 12/2/2020; 12/3/2020-12/6/2020; and 12/13/2020.

3. An interview was conducted with the 3 East Unit Charge Nurse (E#8) on 12/14/2020, at approximately 10:30 AM. E#8 stated that the defibrillator, lock, and oxygen should be checked daily. E#8 stated that every week, the emergency cart should be opened and medications/supplies will be checked for inventory and expiration dates.

4. An interview was conducted with the 3 East / 2 North Unit Manager (E#5) on 12/14/2020, at approximately 12:10 PM. E#5 stated that the 3 East and 2 North Units were not closed in the month of December and that the carts should have been checked every day.

5. An interview was conducted with the OR Operations Lead (E#10) on 12/16/2020, at approximately 10:10 AM. E#10 stated that the crash carts should have been checked weekly for outdated medications and supplies. E#10 stated that Pharmacy typically does a monthly check of the crash carts and will replace any outdated medications.

6. An interview was conducted with the GI Lab Team Lead (E#17) on 12/16/2020, at approximately 11:10 AM. E#17 stated that the cart should have been checked every day the GI Lab was open for procedures. The procedure schedule for November and December 2020 was reviewed with E#17 on the computer and confirmed that the GI Lab was open on the missing dates.

A. Based on document review, observation, and interview, it was determined that for 1 of 2 operating room staff (Registered Nurse/E #11) observed for sterile field setup the Hospital failed to ensure that the policy governing surgical care was implemented, by failing to ensure that sterile OR (Operating Room) packages were not placed on an unclean surface.

Findings include:

1. The policy titled, "Sterile Technique-Preparing and Maintaining the Sterile Field" dated 6/19 was reviewed on 12/16/2020. The policy required, "A. All individuals involved in the operative or other invasive procedures have a responsibility to provide a safe environment for patient care. B. Perioperative team members must be vigilant in preventing contamination of the sterile field and ensuring that the principles and processes of sterile technique are implemented."

2. On 12/16/2020 between 8:55 AM and 11:00 AM, an observational tour of the OR area was conducted. At 9:23 AM in OR #2, during a sterile field setup, a Registered Nurse (E #11) placed three unopened surgical sterile packages on top of an open garbage can. At 9:25 AM, the surgical sterile packages were opened and placed on the sterile field.

3. On 12/16/2020 at 9:27 AM, an interview was conducted with the Surgical Operations Leader (E #10). E #10 stated that although the packages were unopened, the best practice would have been to place the sterile packages on a table and not on the garbage can.


B. Based on document review and interview, it was determined that the Hospital failed to ensure that policies governing surgical care were designed to address malignant hyperthermia (severe reaction to anesthesia drugs) cart management to assure the achievement and maintenance of high standards of patient care.
Findings include:
1. The Hospital's Malignant Hyperthermia Education documents (undated) was reviewed on 12/16/2020 and included a list of cart contents; however, did not address when and how often the cart should be checked.
2. During a tour of the Surgical Department (OR) on 12/16/2020, at approximately 10:00 AM, there was 1 malignant hyperthermia (MH) cart available. The MH cart inspection log from 12/1/2020-12/16/2020 was reviewed and lacked documentation of weekly medication/supply checks. The MH cart contained the following outdated medications:
- Two of 8 boxes (6 vials per box) of dantrolene (muscle relaxant) had an expiration date of 10/2020.
- One of 2 vials of heparin (blood thinner) had an expiration date of 9/2020.
- One of 1 vial of sodium bicarbonate (antacid) had an expiration date of 8/2020.
- One of 1 vial of furosemide (diuretic - used to reduce body fluid) had an expiration date of 8/1/2020.
- One of 1 vial of naloxone (used to treat opioid overdose) had an expiration date of 9/2020.
3. An interview was conducted with the OR Operations Lead (E#10) on 12/16/2020, at approximately 10:10 AM. E#10 stated that there was not a clear system in place to ensure that the malignant hyperthermia cart was checked routinely for outdated medications and supplies. E#10 stated, "I don't believe we have a specific policy on managing the malignant hyperthermia cart."
4. A policy for Malignant Hyperthermia was requested from the Hospital on 12/17/2020, at approximately 8:45 AM. The Quality Risk Specialist (E#18) stated that there was no policy.