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Based on record review, facility policy review and interview the facility failed to protect patients during the investigation and failed to thoroughly investigate an allegation of verbal abuse for one patient (Patient #3) out of out of one allegation investigation reviewed. The census at the time of the survey was nineteen (19) patients.

Findings included:

1. Facility policy titled "Abuse, Neglect and Harassment", number A02-A, last revised 01/10/10 states in part, "An allegation of abuse of a patient by staff, visitors or other patients will result in removal of the patient (and others, as indicated) from any potential for harm or injury. There will be no delay in removing patients from potential of danger pending notifications and investigation. Protection of Patients: Any allegation of abuse or neglect by an employee must result in removal of the patient from potential of further abuse. Any employee involved in such an accusation, will be suspended with pay and instructed not to come to the hospital for any reason, until the investigation is completed and the matter resolved. Investigation: As above, all investigations will be prompt and thorough".

2. Review of a complaint/grievance file on 10/27/10 at 10:00 a.m. which involved an allegation reported by a patient's family that Staff L had been verbally abusive to a patient on 09/20/10 showed the complaint was received by facility staff on 09/21/10. Staff H, RN, Director of Quality Management initiated the investigation on 09/21/10 by interviewing the family who had made the complaint and interviewing Staff L. The allegation was found to be unsubstantiated on 09/21/10.

3. Staff H said the following during an interview on 10/28/10 at 9:00 a.m.:
- He/she had not sent Staff L home and was not sure if Staff L worked with the patient involved during the investigation.
- He/she had interviewed the Occupational Therapist and the Physical Therapist, but had not documented the interviews in the complaint file.
- He/she had not interviewed the charge nurse, other nursing staff or any patients regarding the allegation.

4. Staff N, Occupational Therapist confirmed during an interview on 10/28/10 at 9:28 a.m. that Staff L had worked on 09/21/10 from 8:00 a.m. until 4:30 p.m. and would have been responsible to assist/share with the Physical Therapist to give care for patients with orders for physical therapy on the unit and assist nursing with patient positioning and transfers. Staff N did confirm from the patient's medical record that Staff L had not performed physical therapy to Patient #3 on 09/21/10, but may have assisted nursing transfer or position Patient #3 that day.

Based on observation, policy review and interview, the facility failed to ensure patient's rights to privacy were protected for eight patients (#3, #7, #5, #6, #12, #13, #10, and #11). The facility census was 19 patients.

Findings included:

1. Facility policy titled "Confidentiality of Records", number C07-A, revised 01/01/10 states in part, "All records pertaining to both current and former patients, and all other persons who have been involved with Hospital, shall be considered confidential. Only authorized personnel shall have access to records".

2. While observing care of Patient #3 on 10/25/10 at 2:00 p.m., sheets of patient labels containing full name and date of birth were visualized attached to a cork board in the room.

3. While observing care of Patient #7 on 10/26/10 at 9:15 a.m., sheets of patient labels containing full name and date of birth were visualized attached to a cork board in the room.

4. During an interview on 10/27/10 at 3:30 p.m. Staff A, Chief Nursing Officer (CNO) said that he/she did not know patient labels were being kept in patient rooms.


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5. Observation on 10/26/10 at 11:10 a.m. of Patient #5's room showed a page of labels containing the patient's full name and date of birth. The page was attached to a cork board in the room and visible to anyone who entered.

6. Observation on 10/27/10 at 10:43 a.m. of Patient #6's room showed a page of labels containing the patient's full name and date of birth. The page was attached to a cork board in the room and visible to anyone who entered.

7. Observation on 10/27/10 at 10:53 a.m. of Patient #12's room showed a page of labels containing the patient's full name and date of birth. The page was attached to a cork board in the room and visible to anyone who entered.

8. Observation on 10/27/10 at 10:55 a.m. of Patient #13's room showed a page of labels containing the patient's full name and date of birth. The page was attached to a cork board in the room and visible to anyone who entered.

9. Observation on 10/27/10 at 11:35 a.m. of Patient #10's room showed a page of labels containing the patient's full name and date of birth. The page was attached to a cork board in the room and visible to anyone who entered.

10. Observation on 10/27/10 at 10:40 a.m. outside room 109 showed a mobile cart with dressing supplies on top. A paper was also on top showing names, diagnosis, and room numbers for Patient #11 and Patient #12. The door to room 109 was closed and there were no staff members in the area. A visitor was standing on the other side of the hall who introduced himself/herself to this surveyor as being a salesperson with a medical equipment company.

Based on observation, and medical record review, facility staff failed to follow physician orders for administration of gastrostomy tube feeding for one patient (Patient #3). The census at the time of the survey was nineteen (19) patients.

Findings included:

1. Observation of patient care on 10/25/10 at 2:10 p.m. for Patient #3 showed the gastrostomy tube feeding disconnected. (A tube placed in stomach to administer fluids, medication and nutrition to patients unable to swallow).
Observation at 3:20 p.m. showed Staff F, Registered Nurse enter the room, but did not reconnect the tube feeding.
Observation at 4:10 p.m. showed the tube feeding remained disconnected.

2. Medical record review on 10/26/10 at 10:00 a.m. showed a physician order written on 10/24/10 for the patient to receive tube feeding of Nepro at 35 milliliters per hour (nutrition specifically designed to meet the nutritional needs of patients with renal failure). Nursing notes on 10/25/10 did not show that the tube feeding had been disconnected.

3. The patient did not receive nutrition as ordered by the physician on 10/25/10 for at least two hours. (Surveyors left facility at 4:10 p.m.).

Based on medical record review, facility policy review and interview, facility staff failed to obtain a physician order for transfusion of blood components prior to administration for one patient (#3), failed to obtain a witness to confirm blood was given to correct patient for one patient (#5), and failed to document accurate vital signs for one patient (#5) of two patient records reviewed having received blood products while in the facility. The facility census was 19.

Findings included:

1. Facility policy titled "Blood/Blood Components Administration (Packed Cells, Plasma, Platelets, Cryoprecipitate)", number B04-N and revised 05/13/09 states in part:
"Informed Consent must be obtained after a physician orders transfusion of blood and/or blood components and before the type and cross-match are obtained".
"Cross-matched blood or blood product will be checked with Blood Bank form attached to unit of cells, to the physician order and the patient arm band, by two licensed personnel, one of whom must be an RN."
"Both licensed nurse/RT/physician must sign the Blood Bank form."
"For each separate infusion, vital signs (including temp [temperature]) should be recorded prior to starting, at 15 minutes and immediately post-transfusion or as indicated on the Blood Bank Blood Administration Record."

Review of DaVita Inc. (contract company that performs dialysis at this facility) policy titled, "Administration of Blood and Blood Products", dated as revised 03/10, showed the following (in part):
"Blood is to be administered per physician's order and hospital policy."

Review of DaVita Inc. policy titled, "Administration of Blood", dated as revised 03/10, showed the following (in part):
"Identification of both the patient and the unit of blood must be verified by two (2) licensed personnel, per hospital policy, to ensure that the correct blood will be given to the correct patient per hospital policy."
"Document patient's pre-transfusion vital signs on the flowsheet and on blood transfusion record. Vital signs should be checked and documented per hospital policy."
"Document the blood transfusion, patient's post-transfusion vital signs and patient's response on the flowsheet and on blood transfusion record."

2. Review of Patient #3's current medical record on 10/26/10 showed the following:
- A physician order written on 10/16/10 which said to type and cross fresh frozen plasma (blood product).
- Documentation that one unit of thawed plasma was transfused on 10/16/10.
- No further physician orders in the medical record to transfuse the blood products.

3. Staff E, charge nurse, confirmed on 10/27/10 that there was no physician order in the medical record to administer a blood product on 10/16/10 to Patient #3.


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4. Review of current Patient #5's medical record on 10/26/10 showed the following:
A document titled, "Blood Bank Transfusion Medicine Services" showed one unit of thawed plasma (blood product) was administered on 07/23/10. The section marked, "Transfusionist Certification", which stated "We certify that we have checked the information on this form with the blood component bag labels, the patient wristband, and we have asked the patient to state his/her name (if possible)" was only signed by one Registered Nurse (R.N.). The signature section for the witness was left blank. Vital signs recorded pre-transfusion (11:50 a.m.), at 15 minutes after transfusion began (12:00 noon), and post-transfusion (12:50 p.m.) all showed the blood pressure at 108/58, pulse of 110, and temperature of 98.1. It was unclear at what time the transfusion started and was completed as the date and time fields were not accurately filled in.

Another document titled, "Blood Bank Transfusion Medicine Services" showed a second unit of thawed plasma was administered on 07/23/10. The section marked, "Transfusionist Certification", which stated "We certify that we have checked the information on this form with the blood component bag labels, the patient wristband, and we have asked the patient to state his/her name (if possible)" was only signed by one Registered Nurse (R.N.). The signature section for the witness was left blank. Vital signs recorded pre-transfusion (11:50 a.m.), at 15 minutes after transfusion began (12:00 noon), and post-transfusion (12:50 p.m.) all showed the blood pressure at 108/58, pulse of 110, and temperature of 98.1. It was unclear at what time the transfusion started and was completed as the date and time fields were not accurately filled in.

Review of the form titled, "Hemodialysis Treatment Record", dated 07/23/10, showed Patient #5's vital signs were as follows:
12:00 noon - blood pressure 100/73, pulse 105;
12:30 p.m. - blood pressure 94/67, pulse 104;
12:40 p.m. - blood pressure 100/73, pulse 110.

5. During an interview on 10/26/10 at 3:10 p.m., Chief Nursing Officer, Staff A, confirmed that there was no witness for units of blood administered to Patient #5 on 07/23/10. Staff A confirmed that the vital signs were documented as unchanged throughout the blood administration but differed from the vital signs recorded on the Hemodialysis Treatment Record. Staff A stated that the blood was administered by the dialysis nurse.

6. During an interview on 10/26/10 at 3:10 p.m., Charge Nurse, Staff E, stated that he/she spoke with the dialysis nurse who signed the transfusion form and the Hemodialysis Treatment Record and the dialysis nurse stated that he/she didn't fill out the form (vital signs) even though he/she had signed the form. It was unknown who documented the vital signs.

Based on record review and interview, the facility failed to ensure telephone orders were signed by the physician within 48 hours for two patients (#6 and #5) of 13 current patient records reviewed. The facility census was 19.

Findings included:

1. Review of current Patient #6's medical record on 10/26/10 at 10:05 a.m. showed the following:
- A 3-page form titled, "Admission Orders" written as a telephone order on 10/18/10 at 3:00 p.m. to include, but not limited to, orders for activity, treatment, tube feeding, lab (blood) tests, ventilator settings, wound care, consults to obtain, and medications. These telephone orders were not signed by a physician.
- A form titled, "Physician Order Addendum Hypoglycemia (low blood sugar) Protocol" written as a telephone order on 10/18/10 at 3:00 p.m. The telephone order for this protocol was not signed by a physician.
- A form titled, "Subcutaneous (just beneath the skin) Sliding Scale Insulin (medication to adjust the patient's blood sugar level) Protocol" written as a telephone order on 10/18/10 at 3:00 p.m. The telephone order for this protocol was not signed by a physician.

2. Review of current Patient #5's medical record on 10/26/10 at 1:50 p.m. showed the following:
- A telephone order written on 07/23/10 at 10:15 a.m. for "2 units FFP's [fresh frozen plasma (blood product)]". The telephone order was not signed by a physician until 07/26/10 at 11:00 a.m.
- A form titled, "Restraint Order/Assessment Sheet", with a telephone order for bilateral wrist restraints written on 09/30/10 at 10:00 p.m. The telephone order for these restraints was signed by the physician but there was no date and time with the signature to show when the physician signed.
- A form titled, "Restraint Order/Assessment Sheet", with a telephone order for bilateral wrist restraints written on 10/01/10 at 9:30 a.m. The telephone order for these restraints were not signed by a physician until 10/4/10 at 1:40 p.m.
- A telephone order written on 10/23/10 for:
Doripenem (antibiotic given for infection) 250 mg (milligrams) IV (intravenous - small catheter inserted into the vein) q (every) 12 hours
D/C (discontinue) Zosyn (antibiotic given for infection)
The telephone order had not been signed by a physician.

During an interview on 10/26/10, Chief Nursing Officer, Staff A, confirmed Patient #5's orders for fresh frozen plasma and restraints weren't signed as required.

Based on medical record review, facility policy review and interview, facility staff failed to obtain informed consent for transfusion of blood components prior to administration of blood for one patient (Patient #3) of two patient records reviewed having received blood products while in the facility. The census at the time of the survey was nineteen (19) patients.

Findings included:

1. Facility policy titled "Blood/Blood Components Administration (Packed Cells, Plasma, Platelets, Cryoprecipitate)", number B04-N and revised 05/13/09 states in part, "Informed Consent must be obtained after a physician orders transfusion of blood and/or blood components and before the type and cross-match are obtained. The consent is valid for the duration of stay unless rescinded by the patient/family".

2. Review of Patient #3's current medical record on 10/26/10 showed the following:
- A physician order written on 10/06/10 which said to transfuse two units of packed red blood cells today.
- Documentation that two units of packed red blood cells were transfused on 10/06/10.
- No consent form to administer blood components.

3. Staff E, charge nurse, confirmed on 10/27/10 that there was no consent form in the medical record to transfuse blood products on 10/06/10.

Based on observation, record review, and interview, the facility failed to ensure to ensure staff followed their policy to prevent the risk of transmission of organisms during the care of three patients (#6, #5, and #1) of six patient care observations made while the patient was on contact precautions (isolation) and failed to maintain cleanliness of two of two crash carts (mobile cart with emergency supplies, equipment, and medication used for resuscitation). The facility census was 19.

Findings included:

1. Review of the facility policy IC III-4 titled, "Standard Precautions" provided the following direction (in part):
"Gowns are worn to prevent contamination of clothing and protect the skin of personnel from blood and body fluid exposures."

2. Observation on 10/26/10 at 11:10 a.m. showed Patient #5 receive a wound dressing change to his/her coccyx (tailbone). Registered Nurse (R.N.), Staff C, performed the dressing change and R.N., Wound Care Specialist, Staff D, entered the room to take pictures of the wound and take measurements. While performing these tasks, Staff D's gloves touched the patient's skin around the wound. After taking pictures, Staff D reached under his/her isolation gown with the soiled glove to get a pen to write down the measurements. Staff D didn't find a pen so asked Staff C for a pen. Staff C reached under his/her isolation gown with a gloved hand and retrieved a pen from one pocket and used the other gloved hand to retrieve a piece of paper from another pocket. A sign outside Patient #5's room showed the patient to be on Contact Isolation precautions and instructed persons entering the room to wear a protective gown and gloves.

Review of the infection list provided by the facility showed that Patient #5 was on contact isolation precautions for MRSA (Methicillin-resistant Staphylococcus aureus [infection resistant to antibiotics]).

3. Observation on 10/26/10 at 9:15 a.m. showed Registered Nurse (R.N.), Staff W, administer medications to Patient #6. While administering medications, Staff W reached under his/her isolation gown with a soiled gloved hand to retrieve a syringe of saline (salt water for injection) from his/her pocket. A sign outside Patient #6's room showed the patient to be on Contact Isolation precautions and instructed persons entering the room to wear a protective gown and gloves.

During an interview on 10/26/10 at 3:45 p.m., R.N., Staff W, stated that he/she was aware that they should not have removed the saline syringe from their pocket while wearing protective gown and gloves in a room where the patient was in isolation.

4. During an interview on 10/27/10 at 1:55 p.m., R.N., Infection Control Specialist, Staff I, stated that reaching under an isolation gown is not acceptable.

5. Observation on 10/25/10 at 1:30 p.m. showed contract dialysis Registered Nurse, Staff B, perform dialysis on Patient #1. After dialysis completed, Staff B replaced the two caps covering the dialysis catheter port (catheter inserted into a large vein in the patient's neck). Staff B did not ask Patient #1 to wear a mask or turn his/her head while the caps were replaced. Patient #1 had a trachestomy (airway opening in the neck) and was lying in bed watching television with his/her head faced forward. Patient #1 had responded to other requests appropriately.

During an interview on 10/28/10 at 9:10 a.m., Administrator of DaVita (Dialysis company contracted to perform services in this facility), Staff P, stated that any time the dialysis catheter is open and the patient has a tracheostomy (airway opening in the neck), the patient should wear a mask if they are able to tolerate it. Staff P stated that even if the patient refuses the mask, they are required to offer it.

6. Observation on 10/27/10 at 10:56 a.m. with Charge Nurse, Staff E, showed the Hall A crash cart's (mobile cart with emergency supplies, equipment, and medication used for resuscitation) top surface to be very dusty and a layer of dust covering the emergency equipment on the crash cart.

7. Observation on 10/27/10 at 11:00 a.m. with Charge Nurse, Staff E, showed the Hall B crash cart's top surface to be very dusty and a layer of dust covering the emergency equipment on the crash cart. Staff E stated that it was housekeeping's responsibility to clean the crash cart.