HospitalInspections.org

Based on record review, observation and interview, the hospital failed to meet the requirements for the Condition of Participation for Patient's Rights as evidenced by:


Failing to ensure psychiatric patients in the Emergency Department (ED) awaiting placement into an inpatient psychiatric facility received care in a safe setting. This was evidenced by patients who were assessed to be dangerous to themselves or others being unobserved for extended periods of time in a room/holding area that contained safety and/or ligature risks for 3 of 3 (#R7, R8, R10) current patients being held on Physician Emergency Certificates and by failing to have policies/procedures that addressed levels of observation for psychiatric patients in the Emergency Department (see findings in tag A-0144).

Based on record review, observation and interview, the hospital failed to ensure psychiatric patients in the Emergency Department (ED) awaiting placement into an inpatient psychiatric facility received care in a safe setting. This was evidenced by patients who were assessed to be dangerous to themselves or others being unobserved for extended periods of time in a room/holding area that contained safety and/or ligature risks for 3 of 3 (#R7, R8, R10) current patients being held on Physician Emergency Certificates and by failing to have policies/procedures that addressed levels of observation for psychiatric patients in the Emergency Department.


Findings:


Review of the hospital policy for PEC/CEC (Physician Emergency Certificate/Coroners Emergency Certificate) (protective custody) revealed in part:

3. Security will monitor PEC patients in the emergency department.

8. For Emergency Department, the security officer will complete the Environment of Care checklist at the beginning of each shift, after a visitor leaves and upon patient return to room (smoking, restroom, telephone, etc)

Further review revealed no guidance in the policy for frequency of monitoring suicidal/homicidal patients. There was also no policy for taking the patients outside of the hospital to smoke or escorting patients to the shower room.


Review of the hospital policy for Suicide Observation/Precautions revealed in part:
5. Patient should not be left unattended.


Review of the ED policy for Psychiatric Presentations to the Emergency Department revealed no levels of observation for psychiatric patients.


An observation on 3/19/15, at 10:15 a.m., of the Emergency Department (ED) revealed two security guards standing at a podium at the junction of two hallways. The hallway leading away from the podium contained four rooms on the left side of the hallway. The rooms all had doors that were closed. Upon further observation, room #34 had the lights off. The contents of the room were unable to be visualized unless the surveyors face was pressed to the window and the exterior light was blocked with cupped hands.


Observation (3/19/15, at 10:15 a.m.) through the window revealed inside room #34 was Patient # R7 on a stretcher with a side rail elevated and a sheet on the bed (ligature risk). Review of the medical record for Patient #R7 revealed he had a Physician Emergency Certificate (PEC) dated 3/17/15, at 8:30 p.m. He was listed as being dangerous to himself, dangerous to others, and unable to seek voluntary admission. He was listed as being currently suicidal, homicidal and violent. Further review revealed no documentation of Patient #R7 being observed by the security staff or hospital staff on 3/19/15 for periods lasting 27 minutes between 8:23 a.m. and 8:45 a.m. and 1 hour and 37 minutes between 8:23 a.m. and 10:00 a.m.


Observation (3/19/15, at 10:15 a.m.) through the window revealed inside room #35 was Patient #R8 sleeping on a stretcher in the dark with one side rail raised with a sheet noted to be covering Patient #R8 (ligature risk). An observation on 3/19/15, at 10:35 a.m., revealed Patient #R8 entering a restroom down the hall from her room. The patient was observed closing the door and locking it (indicated by a green to red sign on the outside of the door). S50Security remained outside of the door while she was in the restroom. Upon observation of the restroom after Patient #R8 exited, there were ligature risks of an automatic door closure in the restroom that protruded into the room and a gooseneck faucet on the sink. There was also a plastic bag in the garbage can which could pose a suffocation risk. Review of the medical record for Patient #R8 revealed a PEC dated 3/18/15, at 9:35 p.m. Her mental condition was listed as positive for suicidal ideations. She was also listed as being dangerous to self and unwilling to seek treatment. Further review revealed no documentation of Patient #R8 being observed by the security staff or hospital staff on 3/19/15 for periods lasting 31 minutes between 7:29 a.m. and 8:00 a.m. and 1 hour and 45 minutes between 8:10 a.m. and 9:55 a.m.


Observation (3/19/15, at 10:15 a.m.) through the window revealed inside room #37 was Patient # R10 who was on a stretcher in a dark room. Patient #R10 had an extension cord connected to an IV pump and IV fluid tubing going into his arm (ligature risk). Review of the medical record for Patient #R10 revealed a PEC dated 3/18/15, at 7:30 p.m. The document listed Patient #R10 as being dangerous to self and others and being currently suicidal and homicidal. Further review revealed no documentation of Patient #R10 being observed by the security staff or hospital staff on 3/19/15 from 1:00 a.m. until 6:45 a.m.


In an observation on 3/19/15, at 2:30 p.m., of the shower room located in the ED that was being used for psychiatric patients with S57Security Supervisor, he said he sat outside the closed door of the shower room while the psychiatric patients showered. An observation of the shower room revealed ligature risks including a hand held shower wand with a long cord, a non-break away shower rod, exposed plumbing under the sink, 2 cords from call lights and a large vent in the ceiling. There was also a plastic liner in the garbage can.


In an interview on 3/19/15, at 10:15 a.m., with S50Security, he said he did not document the frequency of his observations of the psychiatric patients. He said he and another guard was currently observing 3 PEC patients, two on the hallway in front of him and one in a room to the right of his podium. He said he was not able to see the patients in any of the psychiatric hold rooms (Rooms #33, #34, #35, #36 and #37) from where he was standing. He also said, he did not have a frequency to observe the patients. He said, he went into the rooms when a nurse went into the rooms for safety reasons and that is what he would document on his Emergency Services Patient Safety Form. He verified although the nurses notes documented the patients as being in "direct visualization of security" it was not possible for him to see the patients from the podium. He said he would walk down the hall periodically but not at any specific frequency.


In an interview on 3/19/15, at 11:10 a.m., with S51ED Manager, he indicated that patients were not automatically assigned to a one to one status or to a constant visual observation status. He said there were no policies for observation levels on the patients in the ED.


In an interview on 3/19/15, at 10:25 a.m., with S33CCS (Critical Care Services) Director, she said that the ED did not have policies about levels of observation on suicidal patients. She also said, she did not have policies for taking psychiatric or suicidal patients to the smoking area or shower room. She also verified the three PEC patients currently on the unit were not being constantly observed or documented on a regular frequency. She also said the doctors did not order observation levels for the patients on psychiatric hold. S33CCS Director agreed the shower room and restroom contained many ligature risks as well as the side rail of the stretchers in the patients' rooms.

30984

Based on interview and record review, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:


1) Administering Diprovan (Propofol) without clarifying a physician's order for titration of a Diprovan infusion for 3 of 3 (#11, #12, #15) patients reviewed for continuous Diprovan infusions out of a total of 32 sampled patients;


2) Administering Levophed without clarifying an incomplete physician's order for 2 of 2 (#11, #24) patients reviewed for continuous Levophed infusions out of a total of 32 sampled patients;


3) Administering Precedex without clarifying an incomplete physician's order for 1 of 1 (#12) patients reviewed for continuous Precedex infusions out of a total of 32 sampled patients;


4) Administering Neosynepherine without clarifying an incomplete physician's order for 1 of 1 (#11) patients reviewed for continuous Neosynephrine infusions out of a total of 32 sampled patients;


5) Administering Dobutamine without clarifying an incomplete physician's order for 1 of 1 (#15) patients reviewed for continuous Dobutamine infusions out of a total of 32 sampled patients.


Findings:


Review of the Hospital policy titled Propofol guidelines- Nursing Guidelines for the Administration of Propofol (Diprivan) to Adult Mechanically Ventilated Patients, origination date: 11/06, revealed in part:

Policy:

Propofol continuous infusion is indicated to relieve anxiety and/or agitation in order to achieve a calm and quiet state in the intubated and mechanically ventilated patient.

Procedure:

Nursing considerations:

1. Propofol will be administered as a continuous infusion, beginning with the dose of 5mcg/kg/min.

2. Doses are titrated every 5-10 minutes in 5-10 mcg/kg/min increments to obtain/maintain desired effects (calm and quiet state or ventilator control as demonstrated by improved ventilator managements, arterial blood gases (ABGs), etcetera.) up to a maximum dose 50 mcg/kg/min or as indicated by the physician order. Doses exceeding 50 mcg/kg/min requires a physician's order.

Special considerations:

1. Propofol may only be administered to intubated and mechanically ventilated patients.

2. Propofol may cause transient hypotension, especially during bolus injection.

6. Propofol should not be discontinued abruptly as this may cause rapid awakening with anxiety, agitation, and resistance to mechanical ventilation.


Monitoring:

The patient's physical state should be assessed during initiation of therapy and when making dose adjustments.

Once desired state is achieved and patient's condition warrants, routine physical assessments may be resumed using the Ramsey Scale (scale for assessing the level of ICU [ Intensive Care Unit] sedation ).

*These recommendations may not be appropriate for all clinical situations. Decisions must be based on the professional judgment of the clinician and consideration of the individual patient circumstances and available resources.

Review of the Hospital policy titled Standard Infusion Concentrations and Precautionary measures, origination date: 06/2004, revealed in part:

Policy Statement:

Intravenous infusions will be prepared using standard concentrations as approved by the Pharmacy and Therapeutics Committee. A physician's order must be generated for any deviation in standard drip concentration. To establish what type of patient monitoring is appropriate, which areas certain medications can safely by administered and to list if medication is an irritant or vesicant.

Standard Concentration Table:

Drug:
Precedex: Sedative Drip;
Bolus:1 microgram (mcg)/kilogram(kg) intravenously (IV) over 10 minutes; Maintenance: 200 mcg in 50 milliliters (ml) normal saline (NS); Start dose: 0.2 mcg/kg/hour(hr);
Maintenance: 0.2-0.7 mcg/kg/hr.
Administration notes: Titrate to desired sedation level;
Nursing Care: Vital signs routine for unit.

Drug:
Levophed: Used as a Vasoconstrictor/Cardiovascular agent;
Maintenance: 4mg in 250 ml 5% Dextrose (D5W) and concentration 16 mcg/ml; Max dose: 12 mcg/minute; Start dose at 8 mcg/minute.
Administration notes: Titrate to ordered parameters- infuse per instructions;

Drug:
Neosynephrine: Used for Vasoconstriction/Cardiovascular agent;
Maintenance: Max dose 180 mcg/minute unless otherwise ordered by physician
Administration notes: Titration to ordered parameters
Nursing Care: Cardiac monitor, Be aware of critical lab values, Vital signs every 5-15 minutes initially for unit. Advance to unit routine vital signs based on achievement of ordered parameters. Nursing Care: Cardiac monitor, Be aware of critical lab values, Vital signs routine for unit.

Dobutamine (Dobutrex): Used to Increase Cardiac Output;
Maintenance: Average dose: 5-10 mcg/kg/min, Max dose: 20 mcg/kg/min for increasing cardiac output; Average dose: 2.5-20 mcg/kg/min, Max dose 40 mcg/kg/min, need MD order to exceed 20 mcg/kg/min for cardiovascular agent.
Administration notes: Titration to ordered parameters
Nursing Care: Cardiac monitor, Be aware of critical lab values, Vital signs every 5-15 minutes initially. Advance to unit routine vital signs based on achievement of ordered parameters.


1) Administering Diprivan (Propofol) without clarifying a physician's order for titration of a Diprivan infusion:


Patient # 11
Review of Patient #11's medical record revealed an admission date of 2/3/15 and an admission diagnosis of Septic Shock. Further review revealed the patient was intubated and required ventilatory support.


Review of the patient's medical record revealed the following order, dated 2/3/15:
Propofol (Diprovan) 10 milligram (mg)/milliliter (ml) emulsion; Ordered dose: 5mcg/kg/min x 119.8 kg; Route: Intravenous; Frequency: Continuous at 3.6 ml/hour. Further review revealed no documented administration instructions . Additional review revealed no documentation of order clarification, by the nursing staff, for desired level of sedation, specific time increments or specific dosages for titration.



Patient # 12
Review of Patient #12's medical record revealed an admission date of 3/11/15 and an admission diagnosis of Open Traumatic Brain Injury. Further review revealed the patient was intubated and required ventilatory support.


Review of the patient's medical record revealed the following order, dated 3/18/15, for Propofol (Diprovan): 10 milligram (mg)/milliliter (ml) emulsion; Ordered dose: 5mcg/kg/min x 117 kg; Route: Intravenous; Frequency: Continuous at 3.5 ml/hour. Further review revealed the following administration instructions: Titrate to keep patient comfortable on vent. Additional review revealed no documentation of order clarification, by the nursing staff, for desired level of sedation, specific time increments or specific dosages for titration.


In an interview on 3/19/15, at 3:00 p.m., with S32Compliance Manager, she confirmed there were no order clarifications, by the nursing staff, for desired level of sedation, specific time increments or specific dosages for titration of Propofol documented in the above referenced patients' (#11,#12) medical record.


Patient #15
Patient #15 was a 77-year-old male admitted to the hospital on 03/09/15 with a diagnosis of aortic valvular disease and coronary artery disease. Patient #15 had surgery on 03/09/15 for an aortic valve repair.

Review of Patient #15's medical record revealed he was admitted to the SICU (surgical intensive care unit on 03/09/15 with the following intravenous medication ordered on 03/10/15 at 7:15 p.m. Propofol (Diprivan) 5 mcg/kg/min (microgram/kilogram/minute) x 94.3 kg (kilogram). The administration instructions were documented as "titrate for sedation."
Further review of the medical record revealed the propofol was administered from 03/10/15 at 7:15 p.m. through 03/12/15 at 2:00 a.m. Dosages ranged from 8.837 mcg/kg/min to 17.674 mcg/kg/min.


In an interview on 03/18/15, at 11:00 a.m., S42RN EMR (Electronic Medical Record Analyst) confirmed there were no specific orders written by the physician for the titration parameters other than "titrate for sedation" and there should have been specific titration orders written by the physician.


In an interview on 03/19/15, at 3:05 p.m., S31Clinical Practice Facilitator indicated the nurse would perform an assessment of the patient and adjust the dosage of the propofol based on the ranges in the pharmacy policy which stated doses are titrated every 5-10 minutes in 5-10 mcg/kg/min increments. S31Clinical Practice Facilitator confirmed there was no physician order written for specific titration of the propofol other than "titrate for sedation" and there was no specific protocol approved by the hospital for specific titration of propofol which did not include dose ranges.


2) Administering Levophed without clarifying an incomplete physician's order:

Patient # 11
Review of Patient # 11's medical record revealed the following order, dated 2/3/15, for Norepinephrine (Levophed): 64 mcg/ml in dextrose 5% (D5W) 250 ml infusion; Rate: 336.9 ml/hr; Frequency: Continuous; Route: Intravenous; Administration instructions: Titrate as needed to keep Systolic Blood Pressure (SBP) greater than 100. Do not exceed 3 mcg/kg/minute. Wean Neosynephrine first. Further review revealed the following administration instructions: Titrate to keep patient comfortable on vent. Additional review revealed no documentation of order clarification, by the nursing staff, for specific time increments or specific dosages for titration.


In an interview on 3/19/15, at 3:00 p.m., with S32Compliance Manager, she confirmed there were no order clarifications, by the nursing staff, for desired level of sedation, specific time increments or specific dosages for titration of Levophed documented in the patient's medical record.


Patient #24
Review of the medical record for Patient #24 revealed the patient was a 73 year old male admitted to the hospital's MICU (Medical Intensive Care Unit) on 03/14/15 with diagnoses of Sepsis secondary to Urinary Tract Infection, Acute Renal Failure, Type II Diabetes Mellitus, Atrial Fibrillation, and Hypokalemia.


Review of the physician's orders revealed an order dated 03/15/15, at 1:30 p.m., for a Levophed (Norepinephrine) infusion to titrate to keep the mean arterial pressure greater than 60. Also included in the order was, "Patient with diagnosis of sepsis, ok to titrate up to 30 mcg/min if needed." The section of the order for titration increments was left blank. Further review of the medical record revealed no documented evidence of an order clarification, by the nursing staff, for specific time increments or specific dosages for the titration of Levophed.


Review of the medical record revealed the Levophed infusion was started on 03/15/15 at 8:50 a.m. at 4.267 mcg/min. Review of the record revealed the patient was currently receiving the Levophed infusion and dose ranges were from 1.6 mcg/min to 11.7 mcg/min.


In an interview on 03/17/15, at 3:30 p.m., S41RN EMR (Electronic Medical Record Analyst) reviewed the electronic record for Patient #24 and confirmed there were no specific orders for how to titrate the Levophed infusion and confirmed there was no documented evidence the RN obtained clarification from the physician for the amount of increments and the timing of the titration.



3) Administering Precedex without clarifying an incomplete physician's order:

Patient # 12
Review of the patient's medical record revealed the following order:
Dexmedetomidine (Precedex) 4 micrograms (mcg)/ml in sodium chloride 0.9% 100 ml;
Ordered dose 0.2-0.7 mcg/kilograms (kg)/hr x 115.1 kg Route: intravenous; Frequency: continuous at 5.8-20.1 ml/hour. Further review revealed the following administration instructions: Titrate for sedation. Additional review revealed no documentation of order clarification, by the nursing staff, for desired level of sedation, specific time increments or specific dosages for titration.


In an interview on 3/19/15, at 3:00 p.m., with S32Compliance Manager, she confirmed there were no order clarifications, by the nursing staff, for desired level of sedation, specific time increments or specific dosages for titration of Dexmedetomidine documented in the patient's medical record.



4) Administering Neosynepherine without clarifying an incomplete physician's order:


Patient # 11
Review of Patient # 11's medical record revealed the following order, dated 2/3/15, for Phenylephrine (Neosynephrine): 0.16 mg/ml in sodium chloride 0.9% 250 ml infusion; Ordered dose: 0.5 mcg/kg/min x 119.8 kg; Route: Intravenous; Frequency: Continuous at 22.5 ml/hr Administration instructions: Titrate as needed to keep Systolic Blood Pressure (SBP) greater than 100. Titrate in 10mcg/min increments. Do not exceed 180 mcg/minute increments. Additional review revealed no documentation of order clarification, by the nursing staff, for specific time increments for titration of the medication the dose.


In an interview on 3/19/15, at 3:00 p.m., with S32Compliance Manager, she confirmed there were no order clarifications, by the nursing staff, specific time increments for titration of Phenylephrine documented in the Patient #11's medical record.



5) Administering Dobutamine without clarifying an incomplete physician's order:


Patient #15:
Review of Patient #15's medical record revealed the following intravenous medication ordered on 03/12/15 at 7:24 a.m. Dobutamine (Dobutrex) 5 mcg/kg/min (microgram/kilogram/minute) x 101.5 kg (kilogram). The administration instructions were documented as "Continuous at 5 mcg/kg/min"


Further review of the medical record revealed the dobutamine was administered from 03/12/15 at 7:53 p.m. through 03/13/15 at 1:39 p.m. Dosages ranged from 5.0 mcg/kg/min to 1.149 mcg/kg/min.


In an interview on 03/18/15, at 10:47 a.m., S42RN EMR (Electronic Medical Record Analyst) confirmed there were no specific orders written by the physician for titration parameters.


In an interview on 03/19/15, at 3:05 p.m., S31Clinical Practice Facilitator indicated under the policy for Standard Infusion Concentration and Precautionary Measures, the "Administration Notes" indicated "Titration to ordered parameters." S31Clinical Practice Facilitator further indicated that a physician needed to write specific titration orders in order for the nurse to titrate medication doses. S31Clinical Practice Facilitator confirmed there was no physician order written for specific titration of the dobutamine, and there was no specific protocol approved by the hospital for specific titration of dobutamine, and there should have been physician orders written for the titration of the medication.


In an interview on 3/18/15, at 1:22 p.m., with S1CNO, she confirmed the medication orders for titration of Levophed, Precedex, and Neosynephrine were incomplete due to their lack of specified time increments and dosing titration increments.


In an interview on 3/18/15, at 2:09 p.m., with S1CNO, she confirmed the nurses should have been clarifying orders. She agreed the orders should have had specific increments and time frames for titrating medications. She also confirmed the sedation orders for Diprovan and Precedex were vague and should have been ordered to a prescribed level of sedation. She agreed orders such as, "titrate to keep patient comfortable on the vent" were vague and left the choice of dose titration increments and time increments up to the interpretation of the nurse administering the medication. She also confirmed the Diprovan protocol contained a dose range and left the incremental changes and time frames open to the interpretation of the nurse administering the medication.


In an interview on 3/19/15, at 11:51 a.m., with S52MICU (Medical Intensive Care Unit) Manager he explained the Diprovan titration was started at the lowest dose of the Diprovan titration dose range and adjusted using the Ramsey sedation scale. He indicated the use of the Ramsey scale was based upon communication with the patient's physician and was not included in the written titration orders. He also agreed titration orders that lacked specific increments and time frames for titrating medications left the choice of dose titration increments and time increments up to the interpretation of the nurse administering the medication.

30364




30984

Based on record review and interview, the hospital failed to ensure the nursing staff developed a comprehensive nursing care plan for each patient by failing to address all identified problems for 8 of 8 (#5, #6, #7, #8, #9, #15 #16, #24) patients reviewed for care planning out of a total sample of 32.


Findings:


Review of the Hospital Policy titled Plan of Care and Patient Education, origination date: 8/1997, revealed in part:

The care plan and education/instruction with the patient and family will be implemented by the admit nurse/Registered Nurse (RN) and continued throughout hospitalization to discharge.
The care plan will be implemented by the admit RN and information added to individualize it throughout the patient's stay in the hospital.

The care plan should be reviewed by the nurse and marked as reviewed by the nurse caring for the patient each day. As the patient condition changes, the care plan should be updated to ensure individualization specific to the patient and diagnoses.


Patient #5
Review of the medical record for Patient #5 revealed the patient was an 84 year old male admitted to the hospital's medical unit on 03/12/15 with diagnoses of Chronic Kidney Disease, Myasthenia Gravis, Sacral Wound, and Weakness. Review of the record revealed the patient was on contact isolation due to a history of MRSA (Methicillin Resistant Staph Aureus).

Review of the record revealed the patient had current wound care orders for 2 wounds, one on the sacrum and another on the toe.

Review of the nursing care plan revealed the only problem identified related to the patient's wounds was, "Skin will experience no new skin breakdown not present prior to admission." There was no documented evidence of the specific interventions related to the patient's wounds in the care plan. Review of the care plan did not include any problem/goal/interventions related to the patient's contact isolation. The patient's Chronic Renal Failure and Myasthenia Gravis was not included in the plan of care.


In an interview on 03/16/15, at 2:15 p.m., S60VP Heart Health Services reviewed the patient's electronic medical record and stated the specific interventions for the patient's wound care were in the physician's orders and confirmed there were no interventions for the wound care in the plan of care. S60VP Heart Health Services confirmed the plan of care did not include all the patient's diagnoses.



Patient #6
Review of the medical record for Patient #6 revealed the patient was a 19 year old female admitted to the hospital's medical unit on 03/12/15 with a diagnosis of Pneumonia.
Review of the record revealed the patient was receiving nebulizer treatments and incentive spirometry. Review of the nursing care plan revealed inadequate gas exchange was identified as a problem, but the interventions were not specific to the patient.


In an interview on 03/16/15 at 3:20 p.m. S41RN EMR reviewed the electronic medical record and confirmed the patient's plan of care did not include individualized interventions for the identified problems.



Patient #7
Review of the medical record for Patient #7 revealed an admission date of 3/9/15 and an admission diagnosis of wound infection. Further review revealed the patient had the following co-morbid conditions/diagnoses: Depression, Hypertension (HTN), Diabetes Mellitus, Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Additional review revealed the patient was on contact isolation precautions.


Review of the care plan for Patient # 7 revealed the following problems were not addressed on the patient's plan of care: Depression, Hypertension, Diabetes Mellitus, MRSA infection and contact isolation precautions.



Patient #8
Review of the medical record for Patient #8 revealed an admission date of 8/25/14 and an admission diagnosis of cellulitis of the legs. Further review revealed the patient had the following co-morbid conditions/diagnoses: Hypothyroidism, Bipolar Disorder and Chronic Obstructive Pulmonary Disease (COPD).

Review of the care plan for Patient #8 revealed the following problems were not addressed on the patient's plan of care: Hypothyroidism, Bipolar Disorder and COPD.



Patient # 9
Review of the medical record for Patient #9 revealed an admission date of 1/27/15 and an admission diagnosis of Confusion/Dialysis complications. Further review revealed the patient had the following co-morbid conditions: HTN, COPD and Psychosis. Additional review revealed the patient was receiving Dialysis treatments three times a week.
.
Review of the care plan for Patient # 9 revealed the following problems/treatments were not addressed on the patient's plan of care: HTN, COPD, Psychosis, and Dialysis.

In an interview on 3/16/15 at 2:00 p.m. with S42RN EMR, he confirmed the above referenced patients' (#7,#8,#9) care plans were not inclusive of all of the patients' diagnoses/problems/treatments.



Patient #16
Review of the medical record for Patient #16 revealed she was a 73 year old female that had been admitted on 3/15/15 with diagnosis that included End Stage Renal Disease (ESRD) which required dialysis.

Review of the care plan for Patient #16 revealed the problem of ESRD requiring dialysis was not addressed.

In an interview on 3/16/15 at 3:30 p.m. with S45LPN, she verified she was the nurse taking care of Patient #16 and did not care plan her dialysis. She said it should have been included in the care plan.



Patient #24
Review of the medical record for Patient #24 revealed the patient was a 73 year old male admitted to the hospital's MICU (Medical Intensive Care Unit) on 03/14/15 with diagnoses of Sepsis secondary to Urinary Tract Infection, Acute Renal Failure, Hypokalemia, Type II Diabetes Mellitus, Atrial Fibrillation, Advanced Dementia with Behavioral Disturbance, and Gastro-esophageal Reflux Disease.

Review of the nursing care plan revealed both excessive nutritional intake and insufficient nutritional intake were identified as problems for Patient #24. Further review of the nursing care plan revealed the patient's diagnoses of Renal Failure, Hypokalemia, Atrial Fibrillation and Advanced Dementia were not included in the plan of care. Review of the the care plan revealed the patient's diagnosis of Sepsis and Urinary Tract Infection were not included in the plan of care, nor was the patient's foley catheter included. Review of the plan of care for the problem areas identified revealed no individualized interventions specific to Patient #24.


In an interview on 03/19/15, at 9:40 a.m., S41RN EMR reviewed the electronic medical record and confirmed the plan of care identified both excessive nutritional intake and insufficient nutritional intake as problems for this patient and she was unable to explain why both were identified as problems. S41RN EMR confirmed the patient's plan of care was not individualized and did not include all the patient's diagnoses. S41RN stated the RN has templates in the electronic medical record that can be selected for the patient. S41RN EMR stated the nurse can add specific patient problems to the care plan.


31048



Patient #15 is a 77-year-old male admitted to the hospital on 03/09/15 with a diagnosis of Aortic Valvular Disease and Coronary Artery Disease. Patient #15 had surgery on 03/09/15 for an Aortic Valve Repair.
A review of Patient #15's medical record revealed Patient #15 remained on a ventilator post-operatively until 03/11/15. Further review of Patient #15's medical record revealed he did not have a care plan for ventilator care.
In an interview on 03/17/15 at 1:15 p.m., S42RN EMR (Electronic Medical Record Analyst) confirmed there was no care plan for ventilator care for Patient #15 and there should have been a care plan for ventilator care.

Based on record review and interview, the hospital failed to ensure drug administration errors and physician notifications of the errors were documented in the medical record.


Findings:


Review of the hospital policy titled Medication Errors revealed in part:

Medication errors not resulting in a need for intervention or change in level of care will be documented in the Significant Event notes for physician notification.


A review was made of a list of medication errors provided by the hospital. The following errors were recorded:

On 2/13/15 at 7:30 a.m., Patient #R5 had an order for 500 ml (milliliter) D20 (20% Dextrose) with 20,000 units of Heparin. Noted during bedside report that bag was 500 ml D5W, however pharmacy label read correct dose of D20. Pharmacy notified and correct bag hung.


On 3/5/15, at 12:03 p.m., in the NICU, PIA (intravenous fluids) arrived on the unit for Patient #19, additives checked and fluid hung. Around 12:18 p.m., pharmacy tech (technician) came in to pick up PIA and return it to pharmacy, told it was already hanging, tech didn't know why it was to be picked up. Pharmacy called by nurse to see what the problem was. Was notified that Potassium Phosphate was omitted during preparation and pharmacist was in route to unit with a syringe of potassium phosphate to add to fluids.


On 3/12/15, Patient #28 was admitted to the floor from PACU (Post Anesthesia Care Unit)at approximately 6:00 p.m. Orders released per day shift nurse. Ancef (Cefazolin) was scheduled on MAR (medication administration record) inaccurately for 6:30 p.m. and was administered at 6:35 p.m. per day shift RN (registered nurse). Pt (patient) received Ancef intra op at 4:15 p.m. The order was for Ancef q8 (every 8 hours).


Review of the medical records for Patient #R5, #19 and #28 with S42RN EMR revealed no documented evidence of the above mentioned medical errors or physician notification of the errors.


In an interview on 3/18/15 at 2:40 p.m. with S1CNO, she verified medication errors and physician notification should have been documented in the patients' medical records.

Based on observations, interviews and record reviews, the hospital failed to ensure the infection control officer maintained an effective system for identifying, reporting, investigating, and controlling of infections and communicable diseases of patients and personnel, as evidenced by:

1) failing to ensure that staff adhered to acceptable standards of professional practice in infection control for the wearing of surgical masks in the semi-restricted and restricted areas,

2) failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers,

3) failing to ensure that equipment available for patient use was not torn/taped to ensure effective infection control cleaning/disinfecting,

4) failing to ensure that EVS (Environmental Services) staff followed acceptable infection control practices when terminal cleaning/disinfecting patient rooms,

5) failing to ensure that staff followed acceptable infection control practices when caring for patients on isolation precautions and when performing patient care tasks: respiratory treatment and foley care.

6) failing to ensure that staff followed acceptable infection control practices during dialysis treatments for 2 (S46RN, S47LPN) of 2 staff observed.


Findings:


1) failing to ensure that staff adhered to acceptable standards of professional practice in infection control for the wearing of surgical masks in the semi-restricted and restricted areas:


The AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices for Hospitals, 2013 edition, a nationally accepted standards of practice was reviewed. The Recommended Practices for Surgical Attire, Recommendation VI, revealed: All individuals entering the restricted surgical area (OR suite) should wear a surgical mask when scrubbed personnel, sterile supplies and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms. The mask should cover the mouth and nose and be secured in a manner to prevent venting. A mask that is securely tied at the back of the head and behind the neck decreases the risk of staff transmitting nasopharyngeal and respiratory microorganisms to patients. Surgical masks should not be worn hanging down from the neck. A further review revealed that surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway and should not be worn hanging from the neck. Surgical masks should be tied securely and discarded after each procedure or when soiled.


Observations on 3/16/15, in the presence of S4VP Surgical Services, revealed the following;

-3/16/15 at 10:10 a.m. in SDS (Same Day Surgery), S7RN (Operating Room Nurse) with her surgical mask hanging down from the neck,

-3/16/15 at 10:20 a.m. in SDS (Same Day Surgery), S8RRT (Operating Room Radiology Technician) with his surgical mask hanging down from the neck,

-3/16/15 at 11:30 a.m. in SDS (Same Day Surgery), S13MD (Anesthesia) with his surgical mask hanging down from the neck,

-3/16/15 at 1:30 p.m. at the operating room nurses's control desk, S17CRNA, S18CRNA, and S20RN (Operating Room Nurse) with their surgical mask hanging down from the neck,

-3/16/15 at 1:40 p.m. in the restricted area where the surgical scrub sinks were located, there was no observations of staff wearing surgical masks while in the presence of scrubbed personnel,

-3/16/15 at 2:30 p.m. in the hallway outside of the operating room, S53LPN/ORT (Operating Room Technician) with her surgical mask hanging down from the neck,

-3/16/15 at 3:00 p.m. in the Sterile Central Process area (also in the presence of S21Sterile Services Manager), S22Sterile Services Tech was observed with her surgical mask hanging down from the neck,

-3/16/15 at 3:00 p.m. in the Sterile Central Process area (also in the presence of S21Sterile Services Manager), there was no observation of staff wearing surgical masks in the Sterile Central Processing area where the autoclaves were processing sterile equipment and sterile supplies for patient use.


In an interview on 3/16/15, at 3:00 p.m., with S4VP Surgical Services, she indicated that she was responsible for Surgical Services to include the Operating Room, SDS, and Sterile Central Processing. The infection control breaches above were addressed with S4VP Surgical Services. S4VP Surgical Services indicated that the surgical scrub sink area was considered part of the Operating Room Suite's restricted surgical area. S4VP Surgical Services further indicated that the hospital followed AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices for Hospitals.


In an interview on 3/16/15, at 3:30 p.m., with S21Sterile Services Manager, in the presence of S4VP Surgical Services, she indicated that she was not aware that staff should wear surgical masks in the autoclave room where the autoclaves were located and where sterile equipment and sterile supplies for patient use were being processed.



2) failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers:


A review of the hospital policy titled, "Blood Glucose Monitoring and Testing", as provided by S2External Review Coordinator as the most current, revealed in part: Glucometers should be cleaned and disinfected after each patient use using a clorox germicidal wipe and allowed to sit for one minute and then dried thoroughly before placing the glucometer back in its case.


An observation on 3/17/15, at 4:00 p.m. revealed the following:

S37RN was observed performing a glucose point of care testing on Patient R2 in the patient's room. After performing the glucose test, S37RN was observed removing her used gloves and picking up the used glucometer with ungloved hands and then bringing the used glucometer to the nurse's station and placing the glucometer on the nurse's desk, while she located the clorox germicidal wipes to clean /disinfect the glucometer. S37RN was not observed allowing the cleaned glucometer to sit for one minute after cleaning nor was she observed drying the glucometer. S37RN was observed immediately placing the glucometer back in its case.



3) failing to ensure that equipment available for patient use was not torn/taped to ensure effective infection control cleaning/disinfecting:


An observation on 3/16/15, at 10:30 a.m., of the SDS's clean supply room, in the presence of S4VP Surgical Services and S5SDS Manager, revealed a patient transfer roller that had a 4 inch tear on the top portion of the roller.


In an interview on 3/16/15, at 10:30 a.m., with S5SDS Manager, in the presence of S4VP Surgical Services, S5SDS Manager indicated that the transfer roller was used to assist in transferring patients to their beds following a patient's surgical procedure. S5SDS Manager further indicated that the patient transfer roller should be replaced when torn.


An observation on 3/16/15, at 2:20 p.m., in the operating room's clean equipment storage area, in the presence of S4VP Surgical Services and S16OR Manager, revealed the following: discolored and torn silk tape taped around a non-disposable nitrogen cord used in the operating room during patient's surgical procedures; large foam padded hand tables x2 used as a positioning device in patient's surgical procedures, that were torn and frayed on the edges of the foam padding; and a large reusable gel pad, used in patient's surgical procedures to protect patient's bony prominent areas and to prevent patient skin break down during surgical procedures, that had a 5 inch tear and several smaller tears on the top portion and where an unknown fluid had seeped into the inner gel material.


In an interview on 3/16/15, at 2:30 p.m., with S4VP Surgical Services and S16OR Manager, S16OR Manager indicated that the above items were reusable and were used during patient's surgical procedures.



4) failing to ensure that EVS (Environmental Services) staff followed acceptable infection control practices when terminal cleaning/disinfecting patient rooms:


A review of the hospital policy titled, "Cleaning Procedures- Environmental Services", as provided by S2External Review Coordinator, as the most current, revealed in part: It is important to minimize air and dust turbulence when cleaning. Dust is hazardous to the hospitalized patient. When cleaning and dusting, the cloth is to be dampened with the hospital's approved disinfectant.


An observation on 3/16/15, at 10:45 a.m., was made of S10EVS Technician performing terminal cleaning of a SDS patient room. S10EVS Technician was observed spraying the hospital's approved disinfectant directly onto the surfaces (bed mattress, overhead table and furniture) and not dampening the cloth with the hospital's approved disinfectant, according to hospital policy. After S10EVS Technician had cleaned the monitor cables and monitor equipment in the SDS patient room with the hospital's approved disinfectant, she began placing clean bed linens on the SDS bed. S11RN entered the room at 11:00 a.m, and told the surveyor that she was directed by her charge nurse to clean the monitor cables and the monitor equipment. S10EVS Technician had indicated to S11RN that she had cleaned the monitor cables and the monitor equipment already. S11RN proceeded to re-clean the monitor cables and monitor equipment again and the now re-wet monitor cables were noted to be coming in contact with the clean bed linens being placed on the bed by S10EVS Technician. After S11RN re-cleaned the monitor cables and monitor equipment, she threw the used disinfectant wipes into the patient trash can in the SDS room, that had already been emptied and re-placed with a new trash bag by S10EVS Technician earlier. S11RN left the SDS room. and was not observed returning to the SDS room to perform any other terminal cleaning activities. After S10EVS Technician had completed the task of placing clean linens onto the SDS bed, she brought the mop into the SDS room and then proceeded to mop the dirty floor.


In an interview on 3/16/15, at 11:20 a.m., with S12 IP Nurse (Infection Prevention Nurse), she was made aware of the above EVS terminal cleaning of the SDS room. S12 IP Nurse indicated that staff did not follow acceptable infection control practices or hospital policy.


5) failing to ensure that staff followed acceptable infection control practices when caring for patients on isolation precautions and when performing patient care tasks: respiratory treatment and foley care:


A review of the hospital policy titled, "Isolation Precaution Definitions and Personnel Protective Equipment", provided by S2External Review Coordinator, as the most current, revealed in part: Staff should change gloves between tasks and procedures on the same patient to prevent cross-contamination. Wash hands immediately after gloves are removed. Use of a antimicrobial agent or a waterless alcohol sanitizer is acceptable.


On 3/17/15 the following infection control breaches were observed:

-3/17/15, at 11:30 a.m., in the SICU (Surgical Intensive Care Unit), in the presence of S29SICU Manager and S31RN, an observation was made of S26PT and S27OT exiting Patient #21's room. Patient #21 was noted to be on contact isolation for MRSA in his sputum. After S26PT and S27OT exited Patient #21's room, they removed their PPE (personnel protective equipment). S27OT was noted wiping her non-disposable eyewear with a disinfectant wipe and then sharing the same disinfectant wipe with S26PT, who proceeded to clean his non-disposable eyewear with the same disinfectant wipe.

-3/17/15, at 11:40 a.m., an observation in the SICU, in the presence of S29SICU Manager and S31RN, was made of S28RN in Patient #21's room, after performing patient care on Patient #21 to perform various non-patient related tasks in Patient #21's room (moving privacy curtains back and arranging room furniture and supplies) without removing her used gloves and donning clean gloves prior to performing other non-patient related tasks.

-3/17/15, at 2:15 p.m., an observation was made of S36RRT, in the presence of S35Patient Services Manager and S1CNO, performing a respiratory treatment on Patient R1 in her room. After S36RRT completed the respiratory treatment on Patient R1 he removed only his right used glove and replaced it with a clean glove. S36RRT did not remove his left used glove. S36RRT proceeded to clean his respiratory equipment, his stethoscope, and the pulse oximeter cable used on the patient with a clean right glove and his used left glove.

-3/18/15 at 10:00 a.m. an observation was made of S40CNA, in the presence of S32Compliance Manager, performing foley catheter care on Patient R4 in her room. S40CNA was observed cleaning Patient R4's upper thigh and groin area first and then cleaning Patient R4's foley catheter tubing (by the meatus) with the same wash cloth. S40CNA was then observed going to Patient R4's sink without changing her gloves and moistening another clean wash cloth, which she used to rinse the patient and the foley catheter. S40CNA was observed obtaining another clean wash cloth which she used to dry Patient R4 and the foley catheter, still using the same used gloves.


In an interview on 3/18/15, at 10:40 p.m., with S3 IC Officer. S3 IC Officer indicated that she was the Director of the Infection Control Department. S3 IC Officer was made aware of the above infection control breaches noted throughout the hospital. S3 IC Officer indicated that these infection control breaches had not been identified by the Infection Control Department and were not acceptable infection control practices. S3 IC Officer further indicated that the hospital followed CDC (Centers for Disease Control) guidelines and AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices for Hospitals


6) failing to ensure that staff followed acceptable infection control practices during dialysis treatments for 2 (S46RN, S47LPN) of 2 staff observed:


Review of the dialysis policy and procedure titled Dialysis Precautions revealed the following in part:

General Approach: Approach all supplies and equipment used for a patient's treatment as if they are contaminated.

Clean area: An area designated for clean and unused equipment, supplies and medications.
Dirty area: An area where this is a potential for contamination with blood or body fluids and areas where contaminated or used supplies, equipment, blood supplies or medications and unused supplies and equipment.

Clean areas should be clearly designated for the preparation and handling and storage of medications and unused supplies and equipment.


Review of the dialysis policy titled Personal Protective Equipment revealed in part:
Change gloves and practice hand hygiene between each patient and/or station to prevent cross contamination.

Remove gloves and wash hands after each patient contact and after exposure to blood and body fluids. If hands are not visibly soiled, use of a waterless antiseptic hand rub is acceptable.

Hand hygiene must always be performed after glove removal.
Gloves- When touching any part of the dialysis machine or equipment at the dialysis station while a patient is connected.


In an observation on 3/16/15, at 10:50 a.m., a cart with clean supplies was in the room with the biohazardous waste and trash.

In an observation on 3/16/15, at 12:45 p.m., S46RN touched the machine at Station #4 and then placed a jug of Natrualyte in the clean supply closet without removing her gloves.

In an observation on 3/16/15, at 12:50, S46RN touched the patient at station #4, then wrote on a paper chart at a bedside computer stand, opened a chlorhexidine prep to clean the patient's cannulation site, and then went to a clean supply cabinet and removed a mask without changing her gloves, washing her hands or sanitizing her hands between the activities.

In an observation on 3/16/15, at 12:48 p.m., S46RN picked up a thermometer from the bedside table at Station #1 and took a temperature on the patient at Station #4 without sanitizing the equipment. S46RN then placed the thermometer on the bedside table of Station #3.

In an observation on 3/16/15, at 1:10 p.m., S47LPN tore tape that was to be used to secure the cannulation needles for dialysis and placed it on the handrail of the bed that had not been cleaned. She then cleaned the insertion site with chlorhexidine, removed her gloves and donned new gloves without sanitizing, and then touched the cannulation site with her gloves before inserting the needle.

In an interview with 3/16/15, at 1:24 p.m., S48Dialysis Coordinator verified she was the supervisor of dialysis. She said the staff should not have touched items at the bedside without gloves. S48Dialysis Coordinator also verified gloves should be removed and hands sanitized between clean and dirty activities. She said the thermometer should be cleaned between patients and the nurses' hands should be sanitized after removing their gloves. S48Dialysis Coordinator verified that the clean supplies should not have been stored in the area where trash and biohazardous waste was collected and stored.






30364

Based on observations, interviews, and record reviews, the hospital failed to ensure the Surgical Services Department followed acceptable professional standards of practice as evidenced by:

1) failing to ensure that staff adhered to acceptable standards of professional practice in the wearing of surgical masks in the semi-restricted and restricted areas, and;

2) failing to ensure that equipment available for patient use in surgical procedures was not torn/taped to ensure effective infection control cleaning/disinfecting,


Findings:

1) failing to ensure that staff adhered to acceptable standards of professional practice in infection control for the wearing of surgical masks in the semi-restricted and restricted areas:


The AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices for Hospitals, 2013 edition, a nationally accepted standards of practice, was reviewed. The Recommended Practices for Surgical Attire, Recommendation VI revealed:

All individuals entering the restricted surgical area (OR suite) should wear a surgical mask when scrubbed personnel, sterile supplies and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms. The mask should cover the mouth and nose and be secured in a manner to prevent venting. A mask that is securely tied at the back of the head and behind the neck decreases the risk of staff transmitting nasopharyngeal and respiratory microorganisms to patients. Surgical masks should not be worn hanging down from the neck. A further review revealed that surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway and should not be worn hanging from the neck. Surgical masks should be tied securely and discarded after each procedure or when soiled.


Observations on 3/16/15, in the presence of S4VP Surgical Services, revealed the following:

-3/16/15 at 10:10 a.m. in SDS (Same Day Surgery), S7RN (Operating Room Nurse) with her surgical mask hanging down from the neck,

-3/16/15 at 10:20 a.m. in SDS (Same Day Surgery), S8RRT (Operating Room Radiology Technician) with his surgical mask hanging down from the neck,

-3/16/15 at 11:30 a.m. in SDS (Same Day Surgery), S13MD (Anesthesia) with his surgical mask hanging down from the neck,

-3/16/15 at 1:30 p.m. at the operating room nurses's control desk, S17CRNA, S18CRNA, and S20RN (Operating Room Nurse) with their surgical mask hanging down from the neck,

-3/16/15 at 1:40 p.m. in the restricted area where the surgical scrub sinks were located, there was no observations of staff wearing surgical masks while in the presence of scrubbed personnel,

-3/16/15 at 2:30 p.m. in the hallway outside of the operating room, S53LPN/ORT (Operating Room Technician) with her surgical mask hanging down from the neck,

-3/16/15 at 3:00 p.m. in the Sterile Central Process area (also in the presence of S21Sterile Services Manager), S22Sterile Services Tech was observed with her surgical mask hanging down from the neck,

-3/16/15 at 3:00 p.m. in the Sterile Central Process area (also in the presence of S21Sterile Services Manager), there was no observation of staff wearing surgical masks in the Sterile Central Processing area where the autoclaves were processing sterile equipment and sterile supplies for patient use.


In an interview on 3/16/15, at 3:00 p.m., with S4VP Surgical Services, she indicated that she was responsible for Surgical Services to include the Operating Room, SDS, and Sterile Central Processing. The infection control breaches above were addressed with S4VP Surgical Services. S4VP Surgical Services indicated that the surgical scrub sink area was considered part of the Operating Room Suite's restricted surgical area. S4VP Surgical Services further indicated that the hospital followed AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices for Hospitals.


In an interview on 3/16/15, at 3:30 p.m., with S21Sterile Services Manager, in the presence of S4VP Surgical Services, she indicated that she was not aware that staff should wear surgical masks in the autoclave room where the autoclaves were located and where sterile equipment and sterile supplies for patient use were being processed.



2) failing to ensure that equipment available for patient use was not torn/taped to ensure effective infection control cleaning/disinfecting:


An observation on 3/16/15, at 10:30 a.m., of the SDS's clean supply room, in the presence of S4VP Surgical Services and S5SDS Manager, revealed a patient transfer roller that had a 4 inch tear on the top portion of the roller.


In an interview on 3/16/15, at 10:30 a.m., with S5SDS Manager, in the presence of S4VP Surgical Services, S5SDS Manager indicated that the transfer roller was used to assist in transferring patients to their beds following a patient's surgical procedure. S5SDS Manager further indicated that the patient transfer roller should be replaced when torn.


An observation on 3/16/15, at 2:20 p.m., in the operating room's clean equipment storage area, in the presence of S4VP Surgical Services and S16OR Manager, revealed the following:

discolored and torn silk tape taped around a non-disposable nitrogen cord used in the operating room during patient's surgical procedures;

large foam padded hand tables x2 used as a positioning device in patient's surgical procedures, that were torn and frayed on the edges of the foam padding; and

a large reusable gel pad, used in patient's surgical procedures to protect patient's bony prominent areas and to prevent patient skin break down during surgical procedures, that had a 5 inch tear and several smaller tears on the top portion and where an unknown fluid had seeped into the inner gel material.


In an interview on 3/16/15, at 2:30 p.m., with S4VP Surgical Services and S16OR Manager, S16OR Manager indicated that the above items were reusable and were used during patient's surgical procedures.

Based on interview and record reviews, the hospital failed to assure that a patient's had a properly executed informed consent as evidenced by failing to include all the required elements in the informed consent that included: the therapeutic alternatives and the risks associated with no treatment, the risks particular to the patient because of a complicating medical condition, the signature of the patient, and/or a treatment change on the informed consent not being initialed by the patient acknowledging the treatment change for 4 (#27, #30, #31, #32) of 5 (#27, #29, #30, #31, #32) patient medical records reviewed for surgical informed consents out of a total sample of 32 patients.


Findings:

A review of the hospital; policy titled, "Informed Consent", as provided by S2External Review Coordinator as the most current, revealed in part:

A properly executed informed consent contains the following elements: hospital name, patient name, name of physician performing the procedure, the general nature of the procedure, the potential benefits, risks and side effects of the procedure, the prospects of success, reasonable alternatives to the procedure and the benefits, risks and side effects associated with any such alternative, risks of not having the treatment, signature of the patient or patient's legal representative, witness signature, and the date and the time consent is signed.


Patient #27
The patient was admitted to the hospital on 3/17/15, for a scheduled surgical procedure. A review of Patient #27's informed surgical consent revealed that the section identifying any additional risks particular to Patient #27 because of any complicating medical conditions and the section identifying any reasonable therapeutic alternatives and risks associated with no treatment was blank.


Patient #30
The patient was admitted to the hospital on 3/17/15, for a scheduled surgical procedure. A review of Patient #30's informed surgical consent revealed that the section identifying any additional risks particular to Patient #30 because of any complicating medical conditions and the section identifying any reasonable therapeutic alternatives and risks associated with no treatment was blank.


Patient #31
The patient was admitted to the hospital on 3/17/15, and was scheduled for a right diagnostic ureteroscopy with stone extraction. A review of Patient #31's informed surgical consent revealed that "stone extraction" was scratched out in the procedure section of the informed consent and there was no evidence on the informed consent indicating that Patient #31 had acknowledged and initialed the change to his surgical procedure.


Patient #32
The patient was admitted to the hospital on 3/17/15, for a scheduled surgical procedure. A review of Patient #32's informed surgical consent revealed the informed consent was witnessed and that the consent was signed by the physician. A further review of Patient #32's informed surgical consent revealed no evidence that Patient #32 had signed the surgical consent and authorized and directed the physician to perform the surgical procedure.



In an interview on 3/19/15, at 4:15 p.m. with S61MD, Chief Medical Officer, he indicated that the above consents did not contain all the elements of a properly executed informed consent.

Based on interview and record reviews, the hospital failed to ensure that patients were informed of the type of anesthesia they were to receive during their surgical procedure that included the expected result, technique and risks associated with that type of anesthesia before the surgical procedure was performed. This failed practice was evidenced by incomplete anesthesia informed consents for 2 (#27, #30) of 5 (#27, #29, #30, #31, #32) patient medical records reviewed for anesthesia informed consents out of a total of 32 sampled patients.


Findings:


Patient #27
The patient was admitted to the hospital on 3/17/15, for a scheduled surgical procedure. A review of Patient #27's completed "Consent for Anesthesia Services" form revealed no indication (no anesthesia type checked on the "Consent for Anesthesia Services" form) of the type of anesthesia that would be used for the surgical procedure, the expected anesthesia result, the anesthesia technique or the anesthesia risks prior to the patient's surgical procedure.


Patient #30
The patient was admitted to the hospital on 3/17/15, for a scheduled surgical procedure. A review of Patient #30's completed "Consent for Anesthesia Services" form revealed no indication (no anesthesia type checked on the "Consent for Anesthesia Services" form) of the type of anesthesia that would be used for the surgical procedure, the expected anesthesia result, the anesthesia technique or the anesthesia risks prior to the patient's surgical procedure.


In an interview on 3/17/15, at 11:30 a.m., with S13MD, Director of Anesthesia, he indicated that the anesthesia, "Consent for Anesthesia Services" form, was to be completely filled out by the anesthesiologist prior to the patient's surgical procedure.

30984

Based on interview and record review, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:


1) Administering Diprovan (Propofol) without clarifying a physician's order for titration of a Diprovan infusion for 3 of 3 (#11, #12, #15) patients reviewed for continuous Diprovan infusions out of a total of 32 sampled patients;


2) Administering Levophed without clarifying an incomplete physician's order for 2 of 2 (#11, #24) patients reviewed for continuous Levophed infusions out of a total of 32 sampled patients;


3) Administering Precedex without clarifying an incomplete physician's order for 1 of 1 (#12) patients reviewed for continuous Precedex infusions out of a total of 32 sampled patients;


4) Administering Neosynepherine without clarifying an incomplete physician's order for 1 of 1 (#11) patients reviewed for continuous Neosynephrine infusions out of a total of 32 sampled patients;


5) Administering Dobutamine without clarifying an incomplete physician's order for 1 of 1 (#15) patients reviewed for continuous Dobutamine infusions out of a total of 32 sampled patients.


Findings:


Review of the Hospital policy titled Propofol guidelines- Nursing Guidelines for the Administration of Propofol (Diprivan) to Adult Mechanically Ventilated Patients, origination date: 11/06, revealed in part:

Policy:

Propofol continuous infusion is indicated to relieve anxiety and/or agitation in order to achieve a calm and quiet state in the intubated and mechanically ventilated patient.

Procedure:

Nursing considerations:

1. Propofol will be administered as a continuous infusion, beginning with the dose of 5mcg/kg/min.

2. Doses are titrated every 5-10 minutes in 5-10 mcg/kg/min increments to obtain/maintain desired effects (calm and quiet state or ventilator control as demonstrated by improved ventilator managements, arterial blood gases (ABGs), etcetera.) up to a maximum dose 50 mcg/kg/min or as indicated by the physician order. Doses exceeding 50 mcg/kg/min requires a physician's order.

Special considerations:

1. Propofol may only be administered to intubated and mechanically ventilated patients.

2. Propofol may cause transient hypotension, especially during bolus injection.

6. Propofol should not be discontinued abruptly as this may cause rapid awakening with anxiety, agitation, and resistance to mechanical ventilation.


Monitoring:

The patient's physical state should be assessed during initiation of therapy and when making dose adjustments.

Once desired state is achieved and patient's condition warrants, routine physical assessments may be resumed using the Ramsey Scale (scale for assessing the level of ICU [ Intensive Care Unit] sedation ).

*These recommendations may not be appropriate for all clinical situations. Decisions must be based on the professional judgment of the clinician and consideration of the individual patient circumstances and available resources.

Review of the Hospital policy titled Standard Infusion Concentrations and Precautionary measures, origination date: 06/2004, revealed in part:

Policy Statement:

Intravenous infusions will be prepared using standard concentrations as approved by the Pharmacy and Therapeutics Committee. A physician's order must be generated for any deviation in standard drip concentration. To establish what type of patient monitoring is appropriate, which areas certain medications can safely by administered and to list if medication is an irritant or vesicant.

Standard Concentration Table:

Drug:
Precedex: Sedative Drip;
Bolus:1 microgram (mcg)/kilogram(kg) intravenously (IV) over 10 minutes; Maintenance: 200 mcg in 50 milliliters (ml) normal saline (NS); Start dose: 0.2 mcg/kg/hour(hr);
Maintenance: 0.2-0.7 mcg/kg/hr.
Administration notes: Titrate to desired sedation level;
Nursing Care: Vital signs routine for unit.

Drug:
Levophed: Used as a Vasoconstrictor/Cardiovascular agent;
Maintenance: 4mg in 250 ml 5% Dextrose (D5W) and concentration 16 mcg/ml; Max dose: 12 mcg/minute; Start dose at 8 mcg/minute.
Administration notes: Titrate to ordered parameters- infuse per instructions;

Drug:
Neosynephrine: Used for Vasoconstriction/Cardiovascular agent;
Maintenance: Max dose 180 mcg/minute unless otherwise ordered by physician
Administration notes: Titration to ordered parameters
Nursing Care: Cardiac monitor, Be aware of critical lab values, Vital signs every 5-15 minutes initially for unit. Advance to unit routine vital signs based on achievement of ordered parameters. Nursing Care: Cardiac monitor, Be aware of critical lab values, Vital signs routine for unit.

Dobutamine (Dobutrex): Used to Increase Cardiac Output;
Maintenance: Average dose: 5-10 mcg/kg/min, Max dose: 20 mcg/kg/min for increasing cardiac output; Average dose: 2.5-20 mcg/kg/min, Max dose 40 mcg/kg/min, need MD order to exceed 20 mcg/kg/min for cardiovascular agent.
Administration notes: Titration to ordered parameters
Nursing Care: Cardiac monitor, Be aware of critical lab values, Vital signs every 5-15 minutes initially. Advance to unit routine vital signs based on achievement of ordered parameters.


1) Administering Diprivan (Propofol) without clarifying a physician's order for titration of a Diprivan infusion:


Patient # 11
Review of Patient #11's medical record revealed an admission date of 2/3/15 and an admission diagnosis of Septic Shock. Further review revealed the patient was intubated and required ventilatory support.


Review of the patient's medical record revealed the following order, dated 2/3/15:
Propofol (Diprovan) 10 milligram (mg)/milliliter (ml) emulsion; Ordered dose: 5mcg/kg/min x 119.8 kg; Route: Intravenous; Frequency: Continuous at 3.6 ml/hour. Further review revealed no documented administration instructions . Additional review revealed no documentation of order clarification, by the nursing staff, for desired level of sedation, specific time increments or specific dosages for titration.



Patient # 12
Review of Patient #12's medical record revealed an admission date of 3/11/15 and an admission diagnosis of Open Traumatic Brain Injury. Further review revealed the patient was intubated and required ventilatory support.


Review of the patient's medical record revealed the following order, dated 3/18/15, for Propofol (Diprovan): 10 milligram (mg)/milliliter (ml) emulsion; Ordered dose: 5mcg/kg/min x 117 kg; Route: Intravenous; Frequency: Continuous at 3.5 ml/hour. Further review revealed the following administration instructions: Titrate to keep patient comfortable on vent. Additional review revealed no documentation of order clarification, by the nursing staff, for desired level of sedation, specific time increments or specific dosages for titration.


In an interview on 3/19/15, at 3:00 p.m., with S32Compliance Manager, she confirmed there were no order clarifications, by the nursing staff, for desired level of sedation, specific time increments or specific dosages for titration of Propofol documented in the above referenced patients' (#11,#12) medical record.


Patient #15
Patient #15 was a 77-year-old male admitted to the hospital on 03/09/15 with a diagnosis of aortic valvular disease and coronary artery disease. Patient #15 had surgery on 03/09/15 for an aortic valve repair.

Review of Patient #15's medical record revealed he was admitted to the SICU (surgical intensive care unit on 03/09/15 with the following intravenous medication ordered on 03/10/15 at 7:15 p.m. Propofol (Diprivan) 5 mcg/kg/min (microgram/kilogram/minute) x 94.3 kg (kilogram). The administration instructions were documented as "titrate for sedation."
Further review of the medical record revealed the propofol was administered from 03/10/15 at 7:15 p.m. through 03/12/15 at 2:00 a.m. Dosages ranged from 8.837 mcg/kg/min to 17.674 mcg/kg/min.


In an interview on 03/18/15, at 11:00 a.m., S42RN EMR (Electronic Medical Record Analyst) confirmed there were no specific orders written by the physician for the titration parameters other than "titrate for sedation" and there should have been specific

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Based on record review and interview, the hospital failed to ensure the nursing staff developed a comprehensive nursing care plan for each patient by failing to address all identified problems for 8 of 8 (#5, #6, #7, #8, #9, #15 #16, #24) patients reviewed for care planning out of a total sample of 32.


Findings:


Review of the Hospital Policy titled Plan of Care and Patient Education, origination date: 8/1997, revealed in part:

The care plan and education/instruction with the patient and family will be implemented by the admit nurse/Registered Nurse (RN) and continued throughout hospitalization to discharge.
The care plan will be implemented by the admit RN and information added to individualize it throughout the patient's stay in the hospital.

The care plan should be reviewed by the nurse and marked as reviewed by the nurse caring for the patient each day. As the patient condition changes, the care plan should be updated to ensure individualization specific to the patient and diagnoses.


Patient #5
Review of the medical record for Patient #5 revealed the patient was an 84 year old male admitted to the hospital's medical unit on 03/12/15 with diagnoses of Chronic Kidney Disease, Myasthenia Gravis, Sacral Wound, and Weakness. Review of the record revealed the patient was on contact isolation due to a history of MRSA (Methicillin Resistant Staph Aureus).

Review of the record revealed the patient had current wound care orders for 2 wounds, one on the sacrum and another on the toe.

Review of the nursing care plan revealed the only problem identified related to the patient's wounds was, "Skin will experience no new skin breakdown not present prior to admission." There was no documented evidence of the specific interventions related to the patient's wounds in the care plan. Review of the care plan did not include any problem/goal/interventions related to the patient's contact isolation. The patient's Chronic Renal Failure and Myasthenia Gravis was not included in the plan of care.


In an interview on 03/16/15, at 2:15 p.m., S60VP Heart Health Services reviewed the patient's electronic medical record and stated the specific interventions for the patient's wound care were in the physician's orders and confirmed there were no interventions for the wound care in the plan of care. S60VP Heart Health Services confirmed the plan of care did not include all the patient's diagnoses.



Patient #6
Review of the medical record for Patient #6 revealed the patient was a 19 year old female admitted to the hospital's medical unit on 03/12/15 with a diagnosis of Pneumonia.
Review of the record revealed the patient was receiving nebulizer treatments and incentive spirometry. Review of the nursing care plan revealed inadequate gas exchange was identified as a problem, but the interventions were not specific to the patient.


In an interview on 03/16/15 at 3:20 p.m. S41RN EMR reviewed the electronic medical record and confirmed the patient's plan of care did not include individualized interventions for the identified problems.



Patient #7
Review of the medical record for Patient #7 revealed an admission date of 3/9/15 and an admission diagnosis of wound infection. Further review revealed the patient had the following co-morbid conditions/diagnoses: Depression, Hypertension (HTN), Diabetes Mellitus, Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Additional review revealed the patient was on contact isolation precautions.


Review of the care plan for Patient # 7 revealed the following problems were not addressed on the patient's plan of care: Depression, Hypertension, Diabetes Mellitus, MRSA infection and contact isolation precautions.



Patient #8
Review of the medical record for Patient #8 revealed an admission date of 8/25/14 and an admission diagnosis of cellulitis of the legs. Further review revealed the patient had the following co-morbid conditions/diagnoses: Hypothyroidism, Bipolar Disorder and Chronic Obstructive Pulmonary Disease (COPD).

Review of the care plan for Patient #8 revealed the following problems were not addressed on the patient's plan of care: Hypothyroidism, Bipolar Disorder and COPD.



Patient # 9
Review of the medical record for Patient #9 revealed an admission date of 1/27/15 and an admission diagnosis of Confusion/Dialysis complications. Further review revealed the patient had the following co-morbid conditions: HTN, COPD and Psychosis. Additional review revealed the patient was receiving Dialysis treatments three times a week.
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Review of the care plan for Patient # 9 revealed the following problems/treatments were not addressed on the patient's plan of care: HTN, COPD, Psychosis, and Dialysis.

In an interview on 3/16/15 at 2:00 p.m. with S42RN EMR, he confirmed the above referenced patients' (#7,#8,#9) care plans were not inclusive of all of the patients' diagnoses/problems/treatments.



Patient #16
Review of the medical record for Patient #16 revealed she was a 73 year old female that had been admitted on 3/15/15 with diagnosis that included End Stage Renal Disease (ESRD) which required dialysis.

Review of the care plan for Patient #16 revealed the problem of ESRD requiring dialysis was not addressed.

In an interview on 3/16/15 at 3:30 p.m. with S45LPN, she verified she was the nurse taking care of Patient #16 and did not care plan her dialysis. She said it should have been included in the care plan.



Patient #24
Review of the medical record for Patient #24 revealed the patient was a 73 year old male admitted to the hospital's MICU (Medical Intensive Care Unit) on 03/14/15 with diagnoses of Sepsis secondary to Urinary Tract Infection, Acute Renal Failure, Hypokalemia, Type II Diabetes Mellitus, Atrial Fibrillation, Advanced Dementia with Behavioral Disturbance, and Gastro-esophageal Reflux Disease.

Review of the nursing care plan revealed both excessive nutritional intake and insufficient nutritional intake were identified as problems for Patient #24. Further review of the nursing care plan revealed the patient's diagnoses of Renal Failure, Hypokalemia, Atrial Fibrillation and Advanced Dementia were not included in the plan of care. Review of the the care plan revealed the patient's diagnosis of Sepsis and Urinary Tract Infection were not included in the plan of care, nor was the patient's foley catheter included. Review of the plan of care for the problem areas identified revealed no individualized interventions specific to Patient #24.


In an interview on 03/19/15, at 9:40 a.m., S41RN EMR reviewed the electronic medical record and confirmed the plan of care identified both excessive nutritional intake and insufficient nutritional intake as problems for this patient and she was unable to explain why both were identified as problems. S41RN EMR confirmed the patient's plan of care was not individualized and did not include all the patient's diagnoses. S41RN stated the RN has templates in the electronic medical record that can be selected for the patient. S41RN EMR stated the nurse can add specific patient problems to the care plan.


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Patient #15 is a 77-year-old male admitted to the hospital on 03/09/15 with a diagnosis of Aortic Valvular Disease and Coronary Artery Disease. Patient #15 had surgery on 03/09/15 for an Aortic Valve Repair.
A review of Patient #15's medical record revealed Patient #15 remained on a ventilator post-operatively until 03/11/15. Further review of Patient #15's medical record revealed he did not have a care plan for ventilator care.
In an interview on 03/17/15 at 1:15 p.m., S42RN EMR (Electronic Medical Record Analyst) confirmed there was no care plan for ventilator care for Patient #15 and there should have been a care plan for ventilator care.

Based on observations, interviews and record reviews, the hospital failed to ensure the infection control officer maintained an effective system for identifying, reporting, investigating, and controlling of infections and communicable diseases of patients and personnel, as evidenced by:

1) failing to ensure that staff adhered to acceptable standards of professional practice in infection control for the wearing of surgical masks in the semi-restricted and restricted areas,

2) failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers,

3) failing to ensure that equipment available for patient use was not torn/taped to ensure effective infection control cleaning/disinfecting,

4) failing to ensure that EVS (Environmental Services) staff followed acceptable infection control practices when terminal cleaning/disinfecting patient rooms,

5) failing to ensure that staff followed acceptable infection control practices when caring for patients on isolation precautions and when performing patient care tasks: respiratory treatment and foley care.

6) failing to ensure that staff followed acceptable infection control practices during dialysis treatments for 2 (S46RN, S47LPN) of 2 staff observed.


Findings:


1) failing to ensure that staff adhered to acceptable standards of professional practice in infection control for the wearing of surgical masks in the semi-restricted and restricted areas:


The AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices for Hospitals, 2013 edition, a nationally accepted standards of practice was reviewed. The Recommended Practices for Surgical Attire, Recommendation VI, revealed: All individuals entering the restricted surgical area (OR suite) should wear a surgical mask when scrubbed personnel, sterile supplies and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms. The mask should cover the mouth and nose and be secured in a manner to prevent venting. A mask that is securely tied at the back of the head and behind the neck decreases the risk of staff transmitting nasopharyngeal and respiratory microorganisms to patients. Surgical masks should not be worn hanging down from the neck. A further review revealed that surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway and should not be worn hanging from the neck. Surgical masks should be tied securely and discarded after each procedure or when soiled.


Observations on 3/16/15, in the presence of S4VP Surgical Services, revealed the following;

-3/16/15 at 10:10 a.m. in SDS (Same Day Surgery), S7RN (Operating Room Nurse) with her surgical mask hanging down from the neck,

-3/16/15 at 10:20 a.m. in SDS (Same Day Surgery), S8RRT (Operating Room Radiology Technician) with his surgical mask hanging down from the neck,

-3/16/15 at 11:30 a.m. in SDS (Same Day Surgery), S13MD (Anesthesia) with his surgical mask hanging down from the neck,

-3/16/15 at 1:30 p.m. at the operating room nurses's control desk, S17CRNA, S18CRNA, and S20RN (Operating Room Nurse) with their surgical mask hanging down from the neck,

-3/16/15 at 1:40 p.m. in the restricted area where the surgical scrub sinks were located, there was no observations of staff wearing surgical masks while in the presence of scrubbed personnel,

-3/16/15 at 2:30 p.m. in the hallway outside of the operating room, S53LPN/ORT (Operating Room Technician) with her surgical mask hanging down from the neck,

-3/16/15 at 3:00 p.m. in the Sterile Central Process area (also in the presence of S21Sterile Services Manager), S22Sterile Services Tech was observed with her surgical mask hanging down from the neck,

-3/16/15 at 3:00 p.m. in the Sterile Central Process area (also in the presence of S21Sterile Services Manager), there was no observation of staff wearing surgical masks in the Sterile Central Processing area where the autoclaves were processing sterile equipment and sterile supplies for patient use.


In an interview on 3/16/15, at 3:00 p.m., with S4VP Surgical Services, she indicated that she was responsible for Surgical Services to include the Operating Room, SDS, and Sterile Central Processing. The infection control breaches above were addressed with S4VP Surgical Services. S4VP Surgical Services indicated that the surgical scrub sink area was considered part of the Operating Room Suite's restricted surgical area. S4VP Surgical Services further indicated that the hospital followed AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices for Hospitals.


In an interview on 3/16/15, at 3:30 p.m., with S21Sterile Services Manager, in the presence of S4VP Surgical Services, she indicated that she was not aware that staff should wear surgical masks in the autoclave room where the autoclaves were located and where sterile equipment and sterile supplies for patient use were being processed.



2) failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers:


A review of the hospital policy titled, "Blood Glucose Monitoring and Testing", as provided by S2External Review Coordinator as the most current, revealed in part: Glucometers should be cleaned and disinfected after each patient use using a clorox germicidal wipe and allowed to sit for one minute and then dried thoroughly before placing the glucometer back in its case.


An observation on 3/17/15, at 4:00 p.m. revealed the following:

S37RN was observed performing a glucose point of care testing on Patient R2 in the patient's room. After performing the glucose test, S37RN was observed removing her used gloves and picking up the used glucometer with ungloved hands and then bringing the used glucometer to the nurse's station and placing the glucometer on the nurse's desk, while she located the clorox germicidal wipes to clean /disinfect the glucometer. S37RN was not observed allowing the cleaned glucometer to sit for one minute after cleaning nor was she observed drying the glucometer. S37RN was observed immediately placing the glucometer back in its case.



3) failing to ensure that equipment available for patient use was not torn/taped to ensure effective infection control cleaning/disinfecting:


An observation on 3/16/15, at 10:30 a.m., of the SDS's clean supply room, in the presence of S4VP Surgical Services and S5SDS Manager, revealed a patient transfer roller that had a 4 inch tear on the top portion of the roller.


In an interview on 3/16/15, at 10:30 a.m., with S5SDS Manager, in the presence of S4VP Surgical Services, S5SDS Manager indicated that the transfer roller was used to assist in transferring patients to their beds following a patient's surgical procedure. S5SDS Manager further indicated that the patient transfer roller should be replaced when torn.


An observation on 3/16/15, at 2:20 p.m., in the operating room's clean equipment storage area, in the presence of S4VP Surgical Services and S16OR Manager, revealed the following: discolored and torn silk tape taped around a non-disposable nitrogen cord used in the operating room during patient's surgical procedures; large foam padded hand tables x2 used as a positioning device in patient's surgical procedures, that were torn and frayed on the edges of the foam padding; and a large reusable gel pad, used in patient's surgical procedures to protect patient's bony prominent areas and to prevent patient skin break down during surgical procedures, that had a 5 inch tear and several smaller tears on the top portion and where an unknown fluid had seeped into the inner gel material.


In an interview on 3/16/15, at 2:30 p.m., with S4VP Surgical Services and S16OR Manager, S16OR Manager indicated that the above items were reusable and were used during patient's surgical procedures.



4) failing to ensure that EVS (Environmental Services) sta