HospitalInspections.org

Based on record review, staff interview and review of policy and procedures it was determined the nursing staff failed to develop and kept current a nursing care plan for three (#3, #4, #17) of thirty seven patients sampled. This does not ensure patient's identified problems/needs are met and the goals are met.

Findings include:

Review of the facility's policy, "Plan for Patient Assessment and Reassessment" last reviewed 9/10 stated the goal of patient assessment/reassessment is to determine the aspects of care required to meet the patient's initial needs as well as his or her needs as they change in response to care. The plan of care is initiated within 24 hours of arrival by the registered nurse (RN). The patient's care needs, and the plan of care required for diagnosis and treatment of the patient are also assessed. The plan of care is updated based on patient progress or upon change in patient condition or diagnosis. Review of the facility's policy, "Skin Care, Prevention and Management of wounds" last reviewed 4/12 stated the goal is to maintain skin integrity of patients. This should occur through initial and ongoing assessment, early, appropriate interventions.

1. Patient #3 was admitted on 6/14/12 for an orthopedic surgical procedure. Review of the initial nursing assessment at 9:00 p.m. revealed the patient had three surgical incisions on the upper left lateral leg. There was no evidence a care plan was implemented for the surgical incisions, wound care or skin integrity. No care plans for the patient were initiated until 6/18/12 at 8:01 a.m.

2. Patient #4 was admitted on 6/15/12 for an orthopedic procedure.
Review of the initial nursing assessment revealed the patient had a right hip surgical incision. There was no documentation a care plan was initiated that addressed the surgical incision, wound care or skin integrity.

Interview with the Nurse Manager of the unit on 6/19/12 confirmed the above findings.

3. Patient #17 was admitted on 6/14/12 with hyperglycemia. Review of the nursing assessment on 6/14/12 and the most current nursing assessment on 6/18/12 at 7:00 a.m. revealed the patient was admitted with diabetic foot ulcers bilaterally, the patient's gait was impaired, the patient was identified as a high fall risk, and the patient was positive for MRSA (Methicillin-resistent Staphylococcus Aureus) with current contact precautions in place.

Review of the patient's plan of care dated 6/18/12 at 2:20 p.m. revealed pain was the only problem/need identified.

Interview with the unit manager and the risk coordinator at the time of the review confirmed the above findings.

Based on policy review, observation, record review and staff interview it was determined the facility failed to label medications per policy and antibiotics administration was delayed for one (#12) of thirty seven patients sampled. This practice does not prompt safe and effective medication therapy.

Findings include:

1. Tour of the Main Pharmacy on 6/19/12 at 9:00 a.m. revealed four intravenous (IV) solutions in the Total Parenteral Nutrition (TPN) Hood with no expiration labels on the IV bags or tubing.

Review of the policy "Sterile Products-Preparation", #13-02, last revised 1/2011, revealed that TPN solutions and tubing are to be changed every 24 hours to prevent microbial growth and contamination.

Interview with the Pharmacy Director on 6/19/12 at 9:00 a.m. revealed that the IV bags and tubing are changed daily and entered into a log. Review of the TPN log with the Pharmacy Director revealed that the IVs were changed on 6/18/12 but there was no time documented in the log.

2. Tour of the Surgical Pharmacy on 6/18/12 at 2:10 p.m. with the Pharmacy Director revealed an IV of sterile water in the sterile hood labeled spiked 6/15/12 p.m. with no time.

Interview with the Pharmacy Director revealed the sterile water was used for dilution of medications, should have been timed and was expired.

3. Patient #12, less than two weeks of age, was a direct admission to the pediatric unit with pneumonia on 6/15/2012 at 1:54 p.m. Review of the physician orders on 6/15/12 at 1:25 p.m. revealed orders for Cefotaxamine 80 milligrams (mg) intravenous (IV) every six hours and Erythromycin 40 mg by mouth every eight hours. Review of the Medication Administration Record (MAR) revealed Cefotaxamine and Erythromycin were administered at 7:18 p.m., approximately six hours later. Review of the nurse's note on 6/15/2012 at 7:18 p.m. revealed the reason the antibiotics were late was due to the medications not being in the automated medication dispensing machine.

Review of the "Medication Administration Policy", MM440-C, effective 4/2012, revealed standardized medications ordered every 6 hours are administered at 6 a.m., noon, 6 p.m. and midnight. Medications not eligible for scheduled dosing times include first doses.

Interview and chart review with the Nurse Manager of Pediatrics on 6/18/12 at 11:55 a.m. revealed the orders were hand carried from the physician's office to the facility by the family, scanned to pharmacy at 3:50 p.m., were not available to administer at 6:00 p.m. and were administered at 7:18 p.m.

Interview with the Pharmacy Director on 6/18/12 at 1:15 p.m. revealed antibiotics are to be given as soon as possible. Chart review with the Pharmacy Director revealed the antibiotics were processed on 6/18/12 at 5:30 p.m.

Based on staff interview, review of policy and procedures, and observation it was determined the facility failed to maintain code carts, warming cabinets, sterilizers and medication refrigerators according to facility policy. It was determined the facility failed to ensure the equipment located in the operating suite was kept free of rust. This practice does not ensure the facility maintains an environment that is clean, safe and in operating condition. This does not ensure a level of safety and quality is maintained.

Findings include:

1. Review of Policy #Pc536, last revised 7/2010, "Cardiopulmonary Resuscitation Provision of Care" stated in section 18: Nursing will check all code carts daily for external supplies, check defibrillator and complete code cart log/checklist. Section 20 of this policy stated: Nursing will check cart monthly for expired supplies on the first day of the month by referring to the label placed by Central Support indicating outdates. Central support is to be called and replacement cart requested.

During tour of the Operating Room Unit on 6/18/2012 at 2:00 p.m. the "Crash Cart Log Sheets" were reviewed with the Director of Surgical Services and the Operating Room Manager. The pediatric and adult checklists were not completed on 6/2/2012, 6/3/2012, 6/9/2012, 6/10/2012, 6/16/2012 and 6/17/2012. The pediatric cart was observed to have a Central Support expired item sticker dated 5/12. Expired items observed in the pediatric cart included (2) nasogastric tubes expired 5/12 enclosed in the pediatric intubation modules and (12) Tegaderm HP expired 3/12.

Interview with the OR Manager on 6/18/12 at 2:00 p.m. confirmed the code carts are to be checked daily and the checks documented on the Crash Cart Log Sheet. The supplies are to be checked monthly for expiration dates.

Interview with the OR Manager revealed Anesthesia Technicians check the carts during the week but they do not currently have a process as to who performs the code cart check on weekends.

2. Review of Policy #W2.0, last revised 4/2013, "Warming Cabinets" procedure V (B) stated: Intravenous (IV) fluid and irrigation fluid should be labeled with the date of discard when placed in warming cabinet; procedure VII stated warming cabinet temperature levels will be recorded daily.

During tour of the Operating Room Unit on 6/18/2012 at 2:00 p.m. (1) 0.9% Sodium Chloride irrigation fluid with no expiration date label was observed in the sub sterile 9-10 warmer. One 0.9% Sodium Chloride irrigation fluid with no expiration date label was observed in the sub sterile 12 warmer. In the sub sterile 5-6 warmer (1) 0.9% Sodium Chloride irrigation fluid was observed with no expiration date label and (1) with an expired label dated 6/18/12.

Review of the "Warmer Log" checklists for blanket warmers and fluid warmers revealed actual temperatures should be written daily. Review of the "Warmer logs" in sub sterile 5-6, 9-10 and 12 revealed the warmer logs were not completed on June 1-3, June 9-12, June 14, and June 16-17. June 4-8 and June 13th had an "X" in the 115 degree temperature line.

Interview with the OR Manager on 6/18/12 at 2:00 p.m. confirmed the logs were incomplete and the actual temperature should have been written on the checklist, not marked with an "X".


3. A tour of the Operating Room was conducted on 6/18/2012 at 2:00 p.m. During the tour rusty wheel castors were observed in Operating rooms 1, 2 and 10. The cryotherapy machine in room 1 had a rusty base and an electrical outlet cover in room 1 was broken, exposing a hole.

The above findings were confirmed at the time of the observation with the Operating Room Manager and the Director of Surgical Services.

4. Review of Policy #506, last revised 4/2012, "Biological Monitoring in the Operating Room" stated in section A: All sterilization equipment will be biologically monitored with an appropriate biological indicator, daily. Procedure B stated routine monitoring is completed daily and documented in log book Procedure B (8) stated the following information will be recorded after each use: patient label, date, time, contents, results, and operator's initials.

Review of the sterilizer log books for sterilizers #1 and #6 with the OR Manager, Manager of Sterile Processing and the Director of Surgical Services on 6/21/12 at 10:00 a.m. revealed the following:
? The inside cover of sterilizer #6 log book had a list of procedures that stated: perform a test run of each autoclave Monday-Friday except weekends and holidays
? Sterilizer #1 did not have a patient label on 6/4/12 at 7:00 a.m. and on 6/14/12 there were no patient labels or documented time on 3 entries.
? Sterilizer #6 on 6/1/12 had no time for one entry
? Sterilizer # 6 at 10:45 a.m. had no patient label or name of a patient listed for a screw set that was sterilized.

Interview and review of sterilization log books with the Operating Room (OR) Manager and the Manager of Sterile Processing on 6/19/12 at approximately 3:00 p.m. revealed the flash sterilizers are not checked daily on weekends.

Interview and review of policy and review of sterilizer logs for Sterilizers #1 and #6 with the OR Manager and the Manager of Sterile Processing on 6/21/12 at 10:30 a.m. confirmed the findings above.

5. Review of policy #821 "Refrigerators-Infection Prevention and Control Guidelines for Storage of Food and Medicine" last reviewed 8/10 stated temperature will be monitored and documented daily.

Review of the "Temperature Log for Refrigerator and Freezer log for Vaccines" stated check the temperatures in both the freezer and the refrigerator compartments of your vaccine storage units at least twice daily. Place an X in the box that corresponds with the temperature, record the room temperature, the time of the temperature readings and your initials.

Tour of the pharmacy and review of the refrigerator/freezer logs in the main pharmacy with the Director of the Pharmacy on 6/18/12 at 1:15 p.m. revealed temperature was not recorded for 6/18/12 a.m.
Interview with the Pharmacy Director revealed the temperatures are checked daily at approximately 8:00 a.m.

The following was observed on the main Pharmacy refrigerator/freezer log:
? Room temperature was not recorded from June 1 to June 18
? Initials were placed in the time section on June 14-15 and no time was recorded
? Initials or dots were placed in the temperature section instead of an X on all dates in June except for two readings.

The following was observed on the Operating Room Pharmacy refrigerator/freezer log on 6/18/12 at 2:10 p.m.
? Room temperature was not recorded June 16-18
? Temperature was not recorded in the evening of 6/16/12
? The only time recorded between 6/16/12-6/18/12 was on 6/17/12 at 3:00 p.m.

Interview with the Director of Pharmacy on 6/18/12 at 2:10 p.m. confirmed the above findings.