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Based on observation, interview, and record review, the facility failed to:

A. ensure testing solution used to determine accuracy of dialysis equipment and dialysis treatment was not expired prior to use.

B. ensure dialysate solution used during patient treatment was not expired and stored in a manner to prevent cross contamination.


Failure to ensure dialysis supplies were used properly put patients at risk for injury, infections, or possible death. These deficient practices placed Patient #'s 1 and 4 and all dialysis patients at risk for the likelihood of harm, injury, or subsequent death.


Refer to tag 0144 for additional information.

Based on observation, interview, and review review, the facility failed to ensure a sanitary environment in 10 of 10 areas (Shower room, Linen room Alcove, Linen Closet, Room #614, Room #612, Environmental Services room, Clean Supply Room, Biohazard Storage Room, Dialysis Supply Room and Conference Room (Pyxis).


Refer to tag 0749 for additional information.

Based on observation, interview, and record review, the facility failed to ensure patient complaints and grievance were addressed and investigated in 3 of 3 incidents.

This deficient practice had the likelihood to cause harm to all patients.


Findings include:


Room Temperatures


Review of facility work orders revealed on 04/06/2017 the air conditioner (AC ) was too cold for patients and it was at 62 degrees. There was no indication as how the complaint was resolved.

Review of the facility's patient and grievance log revealed there was a complaint made about the room temperature being too cold on 05/18/2017. The resolution was that the facility was working with plant ops on temperature control.

Review of the facility's "Complaint Log 2017" revealed only 2 complaints logged. One made mention of the room temperature complaint dated 05/18/2017 and the other was an abuse allegation. There was no documentation of the complaints from 04/06/2017 on the log.

During an observation and interview on 09/19/2017 after 11:00 a.m., a patient complaint was received about the temperature in Room #610. Staff #9 took the temperature of the room and it measured 73.2 degrees Fahrenheit at the vent. Staff #9 reported the temperature should be cooler than that at the vent.


During an interview on 09/19/2017 after 1:00 p.m., Staff #1 reported they did have complaints about room temperatures in the past. Staff #1 reported she did not have a way to pull up all of the complaints that their unit had reported to the main hospital campus. It could not be obtained because they did not have access to that portion of the computerized system.

During an interview on 09/19/2017 after 1:00 p.m., Staff #9 and 10 (from the main campus) reported they controlled the temperatures from the main campus. They had made repairs to the system in the past. They could provide information showing the temperatures were being monitored on the unit.

During an interview on 09/20/2017 after 8:00 a.m., Staff #9 reported they did not have any way of monitoring the temperatures for the unit. They had just fixed the air conditioning system and found that a damper was closed.



Abuse


Review of the grievance log dated 02/06/2017 revealed a patient allegation was made about physical abuse. There was no documented investigation including staff interviews into what occurred.

Review of the facility's policy named "GRIEVANCE" dated 10/2016 revealed the following:

"2."Complaint"Defined:
.....Theses instances are most likely to involve relatively minor complaints about inconveniences, discourtesies or misunderstandings. These complaints are given immediate consideration and are resolved in the most expeditious manner available ...

3. Within three (3) days of the initial Grievance Committee meeting, the committee completes an investigation of the grievance, which may include document review, personal review, policy and procedure review and/or physical inspection.

4. Upon completion of its investigation, the Patient Grievance Committee draws a conclusion as to the validity of the grievance and, if indicated, recommends and implements a course of action to resolve the grievance."

Based on observation, interview, and record review, the facility failed to:

A. ensure testing solution used to determine accuracy of dialysis equipment and dialysis treatment was not expired prior to use.

B. ensure dialysate solution used during patient treatment was not expired and stored in a manner to prevent cross contamination.


Failure to ensure dialysis supplies were used properly put patients at risk for injury, infections, or possible death. These deficient practices placed Patient #'s 1 and 4 and all dialysis patients at risk for the likelihood of harm, injury, or subsequent death.


Findings include:


Review of a facility provided list revealed there had been a total of 16 dialysis treatments provided from 08/14-09/18/2017 to Patient #'s 1 and 4. Dialysis is a procedure of removing, by artificial means, excess water, solutes and toxins from the blood in those whose native kidneys have lost the ability to perform those functions.



During an observation on 09/19/2017 after 12:30 p.m., and 09/20/2017 after 8:30 a.m., the following was found:


Storage room


A Phoenix meter used to test temperature, conductivity (a measure of its ability to conduct electricity) and pH (measure of the degree to which a solution is acidic or alkaline) of dialysis solution was sitting on a table in the room.
Testing solutions used for checking the accuracy of the meter was also on the table in the room.


The following expired bottles of testing solution was found on the same table:

Bottle #1

Conductivity Cell cleaning solution called NeoCare.

There was written documentation that the bottle was opened on 01/13/2017 and expired 03/13/2017 (over 6 months ago).

According to the label on the bottle regular cleaning of conductivity cells is essential in order to maintain accurate and repeatable measurements. NEO-CARE. Cell Cleaning Solution is a gentle, yet highly effective solution that may be used for removing bacterial filming and precipitate buildup that can occur within conductivity cells.



Bottle #2

Conductivity Standard Solution 14.0.

There was a handwritten notation that the bottle was opened on 06/30/2017 and had a discard date of 07/29/2017 (over 1 and ½ month ago).

According to the label on the bottle the solution was used for verifying the accuracy of conductivity meters versus a known standard of conductivity. The standard solution should be used immediately before conductivity meters are used to determine conductivity of dialysate fluid. The instructions read to "Discard 30 days after opening."


Bottle #3

Standard Buffer Solution 7.00 pH.

There was a handwritten notation that the bottle was opened on 06/19/2017 and had a discard date of 09/18/2017.

According to the label on the bottle the solution was used as a secondary standard solution for calibration of meters. There was instructions to "DISCARD 90 DAYS AFTER OPENING"


Bottle #4

Conductivity Standard solution 100.

There was handwritten notation that the bottle was opened on 06/19/2017 and had a discard date of 07/18/2017.

According to the label the solution it was indicated for verifying the accuracy of conductivity meters versus a known standard of conductivity meter are used to determine conductivity of dialysate fluid. The instructions on the bottle read to "Discard 30 days after opening".


Dialysis Supplies

Dialysis supplies were stored on metal shelves which were covered in rust. There was no way the shelves could be sanitized. There was also shipping boxes in the room.

Bottles of dialysate used for patients dialysis treatments named Naturalyte acid concentrate bicarbonate and Centrisol Bicarbonate Hemodialysis Concentrate also stored on the rusted shelves. There were also containers of the dialysate solution stored on the bottom shelves and there was no splash guard underneath them to prevent contamination.



Dialysis Room

A dialyzer was in the room and there were 3 bottles of the Naturalyte acid concentrate bicarbonate (dialysate) sitting on the base of the equipment. All 3 bottles had been opened and a portion of the solution was gone. One bottle had an open date of 09/15/2017. Another one had no open date logged on it and the third bottle revealed an expiration date of 07/2017(over 1 and 1/2 month ago).


The manufacturer's label on the bottles of dialysate solution showed:

CAUTION:..Check conductivity pH of dialyzing fluid before starting treatment and each time solution is added.

WARNING: This acid concentrate product is for use as one component in mixing dialysate bath. This product contains acetic acid and after mixing, yields 4 milliequivalents per liter of acetate in the dialysate. After diffusion across the dialyzer membrane, acetate is metabolized by the liver to serum bicarbonate and adds to the serum bicarbonate that separately results from the diffusion of dialysate bicarbonate across the dialyzer membrane. During dialysis, the dynamic of diffusion and concentration gradients prevent serum bicarbonate concentration from exceeding the dialysate bicarbonate concentration setting on the dialysis machine and is the bicarbonate dose prescribed by the physician.

When the dialysis session terminate, acetate that has not yet metabolized may remain in the blood and will be converted to serum bicarbonate after diffusion ceases, without possibility of diffusion out of the blood. The post dialysis metabolism of acetate could thus briefly increase serum bicarbonate concentration above the prescribed bicarbonate of the dialysate. Physicians should consider this possibility in prescribing bicarbonate dose.

Prescription of insufficient bicarbonate may contribute to metabolic acidosis, excessive bicarbonate may contribute to metabolic alkalosis. Both conditions are associated with poor patient outcomes, including increased mortality risk.


Staff #1, 2,3,4,5 and 6 confirmed the solutions were expired.

Staff #3 reported the last dialysis treatment he had given was on Monday (09/18/2017). Staff #3 reported the solutions and meter were used to check the pH and conductivity of dialysis solution. Staff #3 reported he only used the testing solution marked 14.0 and 7.0. The solution marked 14.0 expired on 07/29/2017 and the solution marked 7.0 expired 09/18/2017. Staff #3 reported he was suppose to document the date opened on all the solution, but this was not done.

There was no way to ensure patients were receiving accurate dialysis treatments by using expired testing solutions on the Phoenix meter and expired dialysate for treatments.


Review of a facility policy named "STORAGE OF ITEMS" dated 08/2015 revealed the following:

.."5. Storage shelves should be cleaned and disinfected at least monthly.
6. Bottom shelves closest to the floor will have a shelf liner in place to protect supplies from debris and mopping ....
8. Outside shipping containers or corrugated containers for distribution or storage are unacceptable."

Based on observation, interview, and record review, the facility failed to ensure registered nurses supervised and evaluated care for 3 of 12 patients (Patient #'s 1, 2 and 3).

This deficient practice had the likelihood to cause harm to all patients.


Findings include:



Review of the clinical record of Patient #2 revealed, he was a 78 year old male who was admitted to the facility on 05/15/2017, diagnoses included myocardial infarction and diabetes mellitus.

Review of the "PATIENT ADMISSION ASSESSMENT" dated 05/15/2017 revealed Patient #2 had two deep tissue wounds on the buttock. There was documentation on the form to "see wound care assessment."

No wound care assessment could be found with the color of the tissue and size of the wounds.


Review of nurses notes dated 05/18/2017 at 7:20 p.m., revealed Patient #2 had a "blister purple in color to R Butt ...."

There was no documentation of the size of the blister and where it was located on the right buttock.


Review of nurses notes dated 05/19/2017 at 11:00 p.m., revealed Patient #2 was "incont of urine skin care provided, shearing 1 blister type sore area to bilat buttock,silvadene calmoseptine cream applied ..."

There was no documentation of the size of or assessment of tissue color of the sores.


Review of nurses notes revealed, Patient #2 was discharged from the facility on 05/20/2017 and there was no documentation of the status of the sores on discharge.



According to nurses notes from 05/15/2017-05/20/2017 revealed Patient #2 had documentation of nurses starting an IV (intravenous) or there being a peripheral IV in place.

Review of physician orders revealed no documentation of an order for an IV to be started.

During an interview on 09/19/2017 after 1:00 p.m., Staff #1 confirmed the missing assessments and there being no order for an IV.



Review of the clinical record of Patient #3 revealed, she was a 90 year old female who presented on 05/19/2017, diagnoses included bilateral aspiration pneumonia and acute/chronic respiratory failure.

Review of physician orders dated 05/19/2017 revealed some of the following orders:
Soft diet
Nutrition consult
Aspiration Precautions
Speech Therapy to eval and treat


Review of the clinical record revealed no care plan with interventions on what to do for a patient on Aspiration precautions.

On 05/23/2017 at 9:00 a.m., an order was written for a clear liquid diet.


Review of the clinical record revealed on 05/23/2017 (4 days after admission) Patient #3 received a dysphagia evaluation from speech therapy. According to the evaluation the recommendation was to continue with clear liquid diet and for swallow precautions.

On 05/23/2017 at 3:30 p.m., a physician's order was written to continue the current diet and for strict swallow precautions posted bedside.


Review of the clinical record revealed on 05/27/2017 (8 days after admission) a nutritional consult was performed.

During an interview on 09/20/2017 after 10:00 a.m., Staff #1 and 11 reported they had no policy on what aspiration and strict swallowing precautions were. Staff #1 reported they had no guidelines on what aspiration precautions should be. Staff #11 reported that speech normally completes the strict swallowing precaution form and checks which interventions they should use. Staff #11 reported that usually when nursing puts the recommendation in for a speech evaluation they respond within 24 hours.



Review of the "PATIENT ADMISSION ASSESSMENT" dated 09/15/2017 revealed Patient #1 was an 81 year old female with a diagnoses of acute respiratory failure. The assessment revealed Patient #1 required total assistance in bed mobility and activity of daily living care.


During an observation on 09/19/2017 after 11:40 a.m., Patient #1 was found to be totally dependent on staff in activities of daily living. When the bed covers were pulled back Patient #1 was noted to have a strong pungent urine odor. Patient #1 was laying on a Chux and incontinent pad. The top of her gown and the top sheet had a dry brown ring from the feces that had pooled between her legs. Patient #1 was soiled with urine from her buttock down to her calves. The edges of the urine had a drying brown ring.

Staff #1 confirmed the condition that Patient #1 was found.

Based on observation, interview, and record review, the facility failed to ensure there was a sanitary environment in 10 of 10 areas (Shower room, Linen room Alcove, Linen Closet, Room #614, Room #612, Environmental Services room, Clean Supply Room, Biohazard Storage Room, Dialysis Supply Room and Conference Room (Pyxis).

This deficient practice had the likelihood to cause harm to all patients.


Findings include:



During an observation on 09/19/2017 after 11:00 a.m., the following was found:


Shower room

A patient geri-chair was stored in the room. The chair had tears in the plastic exposing the cushion underneath. With the tears, there was no way the chair could be sanitized between patient use.

The tile floor in the room had a build-up of dust and dirt.

Patient toilet seat lifts were stored in the room and they were not covered and had no indication they were clean and ready for patient use.

Across from a toilet in the room was an open bin which had clean linen stored in it.


Linen room Alcove

Both clean linen carts had covers which had tears and the wheel casters were rusted.



Linen Closet

The tile flooring in the room was soiled with dirt and dust.

The linen cart was uncovered and there was an air conditioner vent above the linen cart and wires coming from the ceiling.

Clean linen was stacked and touching the walls in the room.

Clean linen was stored on a bottom shelf which had no protective guard on it to prevent contamination.


Room #614

There was an open packet of enteral feeding tube decloggers which had been placed on the windowsill in the room. The packet said they were for single use only. Both decloggers in the packet were soiled build-up of light tan substance and black particles.

On a cabinet in the room were two open 500 milliliter bottles of sterile water.

According to the label on the sterile water they were for single dose and staff were to "Discard unused portion".

There was an open bottle of hydrogen peroxide on the cabinet and had no open date logged on it.

Review of physician orders dated 08/11/2017 revealed one of the admit diagnoses of Patient #4 (in Room #614) was Sepsis (severe blood infection).


Room #612

The tile flooring and the baseboards had a build-up of dirt and entire floor had wax build-up.

A patient toilet seat was found in the shower room which was covered in rust.

The call light system was disconnected from the wall and hanging by the wiring. There was an approximate 2 x 3 inch hole in the wall exposing the insulation and wiring.

The baseboards were taped to the wall in the room.


Environmental Services room

Water stained ceiling tiles were noted in the room. Underneath the ceiling tile were clean floor pads used on the floor waxer.



Clean Supply Room

Plastic bins which contained medical supplies were found to be soiled with debris.


Biohazard Storage Room

The room had a strong foul odor. When the air uptake vent was checked it was not functioning.



Dialysis Supply Room


Dialysis supplies were stored on metal shelves which were covered in rust. There was no way the shelves could be sanitized. There was also shipping boxes in the room.

Bottles of dialysate used for patients dialysis treatments named Naturalyte acid concentrate bicarbonate and Centrisol Bicarbonate Hemodialysis Concentrate also stored on the rusted shelves. There were also containers of the dialysate solution stored on the bottom shelves and there was no splash guard underneath them to prevent contamination.



Conference Room (Pyxis)

There was a Pyxis (medication storage unit) in the room. The plastic medication bins on the inside had a build-up of dried spills, dirt, dust and debris. There were bags of intravenous fluids which did not have an overwrap stored in the soiled bins.

Staff #1 confirmed the observations.


Review monthly environmental rounding sheets from June -August 2017 revealed in June 2017, the dialysis unit was not checked. There were no other problems found in the facility. July 2017 and August 2017 the only problem marked was the extinguishers. The dialysis unit was marked as being satisfactory.

Review of a facility policy named "STORAGE OF ITEMS" dated 08/2015 revealed the following:
"1. Supplies will be stored eight (8) inches from the floor, no closer than eighteen (18) inches from the ceiling, and away from sprinklers and air vents .....

5. Storage shelves should be cleaned and disinfected at least monthly.
6. Bottom shelves closest to the floor will have a shelf liner in place to protect supplies from debris and mopping ....
8. Outside shipping containers or corrugated containers for distribution or storage are unacceptable."

Review of a facility policy named "STANDARD PRECAUTIONS" dated 08/2016 revealed the following:

Patient care equipment ...
"Single-use items that are contaminated are to be disposed of in a plastic lined garbage can or infectious waste container, if necessary."

Routine and Terminal Cleaning
"Each patients' bedside, room and bathroom facilities, is cleaned daily whether the patient is in special precautions or not. All patient rooms are swept, mopped, and the counter surfaces wiped with a hospital approved disinfectant/germicidal solution daily." ....

Linen Precautions ...
"1. Clean linen is delivered to all areas with a cover over the linen cart and a solid bottom shelf., to prevent dust and germs from contaminating the linen prior to use. The linen cart is kept in a designated area with the cover intact. Staff is to lift the cover to remove linen and then replace the cover."