HospitalInspections.org

Based upon review of licensing ,education, certification and training of the Nursing and Respiratory Care and interview with hospital staff the requirement of this regulation were not met as follows:

Findings:

a. In a random review of 14 nursing staff files for current licensing, education, certification and training, it was observed that 3 out of the 14 staff members (21%) files reviewed had advanced cardiac life support certifications that were expired during the validation survey. The facillity's governing body approved position description required these staff members to have current advance cardiac life support (ACLS) certification in this long term acute care facility The expired ACLS certifications included two Respiratory Care Practitioners (files reviewed # 1 and #17) and a License Vocational Nurse (files reviewed #7).

b. Intervewed staff #1, Chief Clinical Officer at 2:25pm on December 4, 2012 in the administration boardroom who also checked the education and training files and verified that the training of these 3 out of 14 staff members were expired and their particular position description did require them to have current ACLS certification. Staff #1 could not show evidence that this requirement was met with these 3 staff education and training files.

1. Based on review of hemodialysis flow sheets, policy and procedures, and staff interview the facility failed to ensure that direct patient care staff reported significant changes in patient health status while receiving hemodialysis to the charge nurse, and failed to ensure that patients were reassessed by a registered nurse when significant changes occurred.

The Findings included:

a.Review of patient #21 hemodialysis flow sheet dated 11/28/12 on 12/4/12 at 11:00a.m. in the facility conference room revealed the following:

Hemodialysis initiated at 06:40a.m. and ended at 10:40a.m. Blood Pressure ranged from 168/87 to 88/44. During treatment patient complained of headache and stomach cramps. No documentation was found that the direct patient care technician notified the registered nurse of the hypotension, headache, and stomach cramps. No documentation was found that the Registered Nurse addressed the hypotension or patient ' s complaints. No documentation found that the RN notified the physician and no documentation found that an adverse occurrence report was completed per policy.

b. Review of Acute Services Policy and Procedure Manuel Hypotension During Treatment on 12/4/12 in the facility conference room stated: Interventions: Notify physician, Reassess patient and complete an Adverse Occurrence Report

c. An interview conducted with (S15) on 12/4/12 at 1:05p.m. following her own review of the findings revealed she was aware of the discrepancies found. (S15) stated that direct patient care technicians do not have written guidelines of reportable incidences to the registered nurse. At the time of the interview no evidence of compliance was presented where noncompliance was found.

Based on review of Quality Performance Meeting minutes and staff interview the facility failed to use data collected to identify opportunities for improvement and changes that would lead to improvement. The facility failed to implement an action plan to identify, implement, and track performance in regard to medication errors.

The findings included:

a. During review of Quality Performance meeting minutes on 12/5/12 at 10:45 a.m. in a room in the hospital titled "2012-3rd Qtr. Risk Management Report" stated "Summary of Findings: Medication errors decreased in the 3rd Qtr. This can be attributed to the lack of time by pharmacy to monitor errors as efficiently in the past due to the increased time being spent on cart fills". "Action to be taken: PI Team on med omissions currently being conducted". No Performance Improvement (PI) Team audits or plans of correction or action plans was found or presented by the facility staff. Last Performance Improvement Team action plan was developed and presented on 6/20/12; no updates to the action plan of 6/20/12 was presented to the surveyors by the facility staff.

b. Interview with (S4) on 12/5/12 at 11:00 a.m. in room 218 at the facility revealed the facility had changed systems at the time of the sale of the hospital to another company and the system was changed to a manual fill system thus taking more time of the pharmacy personnel. (S4) further stated he did not believe the data collected was accurate thus the statement he provided in his notes presented at the Quality Council meeting.
Interview with (S8) on 12/5/12 at 11:25 a.m. in room 218 at the facility revealed the facility had been recently purchased by another hospital system and at the moment the change in the dispensing system had resulted in the pharmacy having to do manual fills and manual counts due to the systems not talking to one another. (S8) further stated when meds are returned in the drawer they credit the system and are not sure if the medication was omitted or had been pulled from the Med Dispense; she stated this is due to a lack of communication between the systems. (S8) stated the pharmacy used to write omissions reports for medications but they currently do not have the time to do this since they went to a manual system. (S8) stated this is due to a lack of interface between the systems and they are unable to determine the accuracy of the data reported.
Interview with (S1) on 12/5/12 at 11:40 a.m. in room 218 of the facility revealed they had gone to a manual system when they no longer were using the previous system for dispensing and tracking medication. Since 8/18/12 they have been using a manual override and there is no check and balance between what is credited as to what is dispensed.
(S1, S4, & S8) all stated during their interviews this is a problem that will be fixed when they relocate to their new building, they are just not sure when that date will be as of this time. (S1) stated there is an increased risk for medication errors and omissions due to the lack of interface with the current system and the increased time spent with the manual fills.

1. Based on review of hemodialysis flow sheets, policy and procedures, and staff interview the facility failed to ensure that direct patient care staff reported significant changes in patient health status while receiving hemodialysis to the charge nurse, and failed to ensure that patients were reassessed by a registered nurse when significant changes occurred.

The Findings included:

a.Review of patient #21 hemodialysis flow sheet dated 11/28/12 on 12/4/12 at 11:00a.m. in the facility conference room revealed the following:

Hemodialysis initiated at 06:40a.m. and ended at 10:40a.m. Blood Pressure ranged from 168/87 to 88/44. During treatment patient complained of headache and stomach cramps. No documentation was found that the direct patient care technician notified the registered nurse of the hypotension, headache, and stomach cramps. No documentation was found that the Registered Nurse addressed the hypotension or patient ' s complaints. No documentation found that the RN notified the physician and no documentation found that an adverse occurrence report was completed per policy.

b. Review of Acute Services Policy and Procedure Manuel Hypotension During Treatment on 12/4/12 in the facility conference room stated: Interventions: Notify physician, Reassess patient and complete an Adverse Occurrence Report

c. An interview conducted with (S15) on 12/4/12 at 1:05p.m. following her own review of the findings revealed she was aware of the discrepancies found. (S15) stated that direct patient care technicians do not have written guidelines of reportable incidences to the registered nurse. At the time of the interview no evidence of compliance was presented where noncompliance was found.

1. Based on visual inspections, personal interviews and reviews of policies and procedures Promise Hospital of San Antonio failed to maintain established procedures for storage, transport, and disposal of trash and bio-hazardous waste.
The findings included:
a. During an inspection of the dirty utility room on 12/4/12 at 10:00 a.m. with the infection control practitioner present we observed both bio-hazardous waste and regular trash receptacles with no lids on. The receptacles were full and overflowing and impeding the flow of traffic in the room. Environmental staff from the host hospital were observed transporting trash/dirty linen as well supplies in carts with no lids or method to protect the contents or eliminate potential cross infection of bio-hazardous waste or dirty linen.
b. An interview with staff member #2 on 12/4/12 at 1:00 p.m. in conference room following her own review of the policies and procedures and observation of the utility room she acknowledged the deficient practice and could not provide any evidence of compliance with the requirement.