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Based on record review and interview, the facility failed to complete a document "Informed Advanced Directive " (IAD) a form given to the patient or the patient's legal representative regarding directives concerning health care decisions and notice of privacy rights. Three patients (Patient 19, 20 and 27) in a sample size of 39 who had completed the IAD form were not witnessed, signed or dated.

Findings:

1. Record review done on 11/1/11 at 10:00 AM, showed that Patient 19 was admitted to the facility on 9/17/11 with the admitting diagnosis of breast cancer.

Review of the IAD form showed that Patient 19 completed the form on 9/15/11. There was no signature of the witness and the date on the IAD form to certify that the undersigned has read the information.

2. Record review done on 11/1/11 at 10:30 AM, showed that Patient 20 was admitted to the facility on 8/16/11 with the admitting diagnosis of left shoulder pain.

Review of the IAD form showed that Patient 20 signed and completed the form on 8/16/11. There was no signature of the witness and the date on the IAD form to certify that the undersigned has read the information, and certifies that the patient's legal representative was duly authorized by the patient to execute the patient's directives and accept its terms.

3. Record review done on 11/1/11 at 11:00 AM, showed that Patient 27 was admitted to the facility on 10/10/11 with the admitting diagnosis of lumbo-sacral disc degeneration.

Review of the IAD form showed that Patient 27 completed and signed the form on 10/10/11. There was no signature of the witness and the date on the IAD form to certify that the undersigned has read the information and given the opportunity to have any questions answered and received a copy of the agreement.

In an interview with the Licensed Nurse/Quality Assurance Manager (LN/Q AM) conducted on 11/1/11 at 3:30 PM, the LN/Q AM stated that the " Informed Advanced Directive " form has to be signed by the witness after the patient/patient's legal representative completes the document.

Based on record review and interview, the hospital failed to ensure the policy and procedure on patient controlled analgesia (PCA) was consistently implemented for patient safety for one (Patient 13) of 39 sampled patients. Patient 13 was not monitored for vital signs, sedation level and pain level in accordance to hospital policy and procedure while on intravenous infusion of narcotics delivered by patient controlled analgesia (PCA).

Findings:

A review of Patient 13's clinical record showed that the patient was admitted to the hospital on 10/13/11 for surgical procedure. The following PCA ordered was prescribed on 10/13/11 for post-operative pain management:

Morphine (a narcotic pain reliever) 1 mg/ml (milligram per milliliter, unit of concentration) PCA
Basal rate: 0.5 mg per hour continuously
PCA: 0.5 mg every 10 minutes

Patient 13's clinical record showed that the PCA was started at 5:00 p.m. on 10/13/11. Patient 13's flow sheet showed that the patient was first assessed for vital signs, sedation level and pain level at 5:50 p.m. and subsequently at 8:00 p.m.

A review of the hospital policy and procedure titled " Patient Controlled Analgesia " dated indicated that patient monitoring including vital signs, analgesia/sedation, pain level should be assessed by registered nurses 15 minutes after the initiation of PCA and then at least every 2 hours or more frequently if patient's condition indicated.

According to Lexi-Comp, national drug information provider for health care professionals, Morphine is in a potent narcotic pain reliever used to treat moderate to severe pain. Continuous intravenous administration of morphine provides a fast and continuous delivery of the medication for pain control. Patients on morphine should be monitored for pain relief, respiratory and mental status, and blood pressure. Overdose of morphine may cause extreme drowsiness, pinpoint pupils, confusion, cold and clammy skin, weak pulse, shallow breathing, fainting, or death.

Based on medical record review, and Dietary Management Staff A and RD B interview the hospital failed to ensure hospital menus provided physician's therapeutic diet order for 1 of 5 patients reviewed for nutritional care.

Findings:

Patient 9 was admitted on 10/25/11 with diagnoses including diabetes mellitus (DM) Type II (a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency) and Right carpal tunnel release. The physician diet order dated 10/25/11 was 1800 Calorie ADA (American Diabetes Association). On 10/26/11 Registered Staff B completed Patient 9 nutrition assessment and recommended the patient continue with the 1800 Calorie ADA diet.

On 11/2/11 at 10:30 a.m. during lunch meal preparation observations, the surveyor observed several different colored menus and asked DMS A what menu would be served to a patient with physician order 1800 Calorie ADA diet. DMS A stated " We don't follow Calorie levels, we do carbohydrate counting. " Concurrently, DMS A pulled a pink menu from the file and labeled Regular Carb Counting- Recommend 4 Carb (carbohydrates) /meal for DM II. Additionally, DMS A stated "As long as they don't order more than 4 carbs per meal it is ok."

On 11/2/11 at 11:00 a.m. review of the hospital/RD approved diet manual dated 2011 confirmed individuals with DM II would be provided with diets based on carbohydrate counting.

On 11/3/11 at 1:30 p.m. during phone interview, RD Staff B confirmed the hospital did not provide Calorie level diets, and did not know why she had approved that diet be served to the patient. She stated the diet provided to Patient 9 was of indeterminate Calories. She stated she had provided training about carb counting to the nurses but not the physicians who ordered the diets. RD Staff B acknowledged the diet order should have been clarified with the physician to ensure the patient received the diet he ordered.

Based on observation, interview and document review, the hospital failed to develop and maintain the safety and well-being of patients when:

1. The planned disaster menu did not meet the nutritional needs of the hospitalized patients and support staff. This put patients at nutrition risk in the event of a disaster that required the hospital to shelter in place with no outside resources available.

2. The facility failed to secure the Operating Room entrance from unauthorized personnel. This had the potential to breach the security of patients and supplies in addition to infection control.

Findings:

1. On 10/31/11 between 11:30 a.m.-12:00 p.m. during review of the hospital disaster menu and observation of the associated foods that would be provided to patients and staff in the event of a disaster that required the hospital to shelter in place with no additional resources, it was revealed the nutritional quality of the menu was unknown. During concurrent interview, DMS A acknowledged the quality of available foods had not been a consideration in planning the menu. DMS A stated " the previous registered dietitian wrote it . There is no nutrition analysis. "




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2. During the initial entrance of the survey team on 10/31/11 at 9:30 AM, various people were observed entering and exiting the "Employee Entrance". This entrance led into a hallway that included doors leading directly into the Operating Room. The entrance doors remained unlocked to the outside which led into the parking lot and eventually into the busy street.

During another observation on 11/02/11 between 11:15 AM to 11:30 AM, the surveyor noted that the Employee Entrance remained unlocked and various people were entering and exiting through the doors.

During an interview on 11/02/11 at 2:25 PM, the Infection Control Preventionist acknowledged that the Employee Entrance doors were unsecured. The exit doors including the Employee Entrance were locked during the evening and night shifts. She stated that she would prefer the doors be locked for security and infection control purposes at all times.

Based on observation, interview and document review, the hospital failed to ensure comprehensive infection control practices that would prevent food-borne illness as evidenced by:
1) Unsafe food handling practices:
a) Undated, opened ground turkey were available for use,
b) Ice machine in the kitchen that provided ice for patient meal service was dirty, and not cleaned and sanitized using chemicals approved by the manufacturer.
c) The dietary services supervisor did not have recent food safety training.
These practices put patients at risk of food-borne illness, which can cause nausea, vomiting, and diarrhea.


Findings:

On 10/31/11 between 10:50 a.m.-11:50 a.m. during initial observations with Dietary Management Staff A (DMS A) in the reach-in freezer there were 2 5-pound bags of undated, ground turkey out of the original packaging. One bag had been opened and approximately three quarters of the contents removed and then frozen or re-frozen. During a concurrent interview, DMS A stated " they (both packages) should have been dated. " According to facility policy NUTR-4.61, approved 6/10, any item not in original packaging would be dated with the open date. Additionally, the facility provided the undated policy " Food Storage Guidelines for Leftovers " that directed ground poultry had a three month frozen storage life.

On 11/2/11 at 11:15 a.m. the kitchen ice machine was observed to have a coating of greyish debris on the door interior as well as on the front of the interior ice-maker cover. During a concurrent interview, DMS A stated the ice machine was cleaned quarterly with Lime-A-Way (a chemical de-scaler), rinsed with clean water and then sanitized with quaternary ammonia. During concurrent review of the manufacturer ' s cleaning/sanitizing guidance printed directly on the machine, it was revealed " Do not use ammonia based cleaners " . The guidance directed the sanitizer to be a 200 ppm (parts per million) of 5.25 percent sodium hypochlorite. At 11:30 a.m., DMS A acknowledged the product used to sanitize the ice machine was not correct per manufacturer ' s guidance.

On 11/2/11 at 10:00 p.m. during an interview regarding her training in food safety and sanitation, DMS A reported she had not had training since 1997 when a student. According to the California Food Code 2009, DMS A should have passed a food safety exam every five years to remain up to date on the subject. During the interview, DMS A stated she had not been aware of this requirement.

Based on record review and interview, the hospital failed to ensure that medications were administered in accordance to the physician's order for one of 39 sampled patients (Patient 15). Patient 15 was administered Hydromorphone (a narcotic pain medication) for pain management not as ordered by the physician.

Findings:

A review of Patient 15's clinical record with the hospital Director of Nursing (DON) showed that the patient was admitted to the hospital on 10/13/11 for surgical procedure. Patient 15 was prescribed the following medications for post-operative pain control on 10/13/11:

Hydromorphone 4 mg by mouth as needed for mild pain.
Hydromorphone 8 mg by mouth as needed for moderate and severe pain.

The DON stated during record review that, according to the hospital pain management policy and procedure, mild pain was defined as pain level of 1 to 3 and moderate to severe pain was defined as pain level of 4 to 10.

Patient 15's flow sheet showed that the patient reported pain level of 4 at 6:00 a.m. on 10/13/11. Patient 15 ' s Medication Administration Record (MAR) showed that the patient was administered Hydromorphone 4 mg at 6:00 a.m. on 10/13/11.

According to the physician's order on 10/13/11, Patient 15 should be administered Hydromorphone 8 mg for the reported pain level of 4.