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Based on interview and record review, the hospital failed to provide one of 23 sampled patients (Patient 82) with discharge instructions in a language the patient could understand. This could potentially result in the patient not knowing what to do after discharge.

Findings:

On 7/26/11, a review of Patient 82's medical record showed the patient had a surgical procedure on 7/16/11. The patient's primary language was not English. The patient's Conditions of Admission paperwork, dated 7/16/11, which included areas such as patient rights etc. was in the patient's primary language. The patient's surgical consent dated 7/26/11, was in English but had a translator's co-signature showing the consent had been translated for the patient.

On 7/16/11, the patient was discharged and given discharge instructions in English. The discharge instructions provided the after surgery care, diet and activity level that were safe for the the patient immediately after surgery. The instructions included to maintain a light activity level for 24 hours, take clear liquids initially as a diet, not to drive for 48 hours, not to drink alcohol for 24 hours, and to keep the surgical site clean and dry.

When asked to review the discharge instructions for Patient 82 on 7/26/11 at 1030 hours, the OR Director stated the hospital did not have discharge instructions available in the patient's language.

Based on observation, record review and interview, the hospital failed to ensure records were kept to show the flow of drugs from their entry into the hospital through dispensation/administration to the patient. The AMD cabinets used in the hospital were not profiled, which allowed a licensed nurse to remove any drug in the AMD cabinet without a valid physician's order or review by a pharmacist prior to the first dose administered to a patient. This resulted in a lack of accountability for the drugs used in the hospital. In addition, the hospital failed to follow current standards for emergency medication use in the OR and PACU.

Findings:

1. On 7/26/11 at 1035 hours, the drug inventory of the AMD cabinet located on the Medical-Surgical unit was reviewed with Pharmacist 1. The review showed the AMD cabinets in the hospital were set up to permit a licensed nurse to remove any drug from the cabinet's inventory without a pharmacist's review. In addition there was no policy or audit process to ensure that a drug removed from the AMD cabinet was actually administered to a patient, thereby ensuring accountability for the drugs used in the hospital.


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2. The 2010 AHA (American Heart Association) guidelines for ALS (Advanced Life Support) contained changes, from earlier guidelines, in the procedures and medications used in emergency resuscitation. For example, Atropine (used to increase heart rate in emergencies) was no longer used when a heart was not beating. In addition, other medications had been introduced for the treatment of abnormal heart rhythms.

On 7/25/11, from 0930 hours to 1000 hours, the crash cart log binders were reviewed in the OR and PACU areas. When opened, the binders contained the 2005 AHA Guidelines for Advanced Cardiac Life Support. When brought to the attention of the OR Director, the Director stated the new guidelines were in the books; however, when found, the new guidelines were in a side pocket of the binder, not readily visible to staff.

Based on observation, interview and record review, the hospital failed to ensure the hospital's policy and procedure for oxygen therapy was followed for one of 23 sampled patients (Patient 74). This could potentially result in unsafe patient care.

Findings:

A review of the hospital's P&P titled Cardiopulmonary Services showed staff would assure the proper and correct use of nasal oxygen in accordance with a physician's order.

On 7/25/11 at 1350 hours, Patient 74 was observed with a nasal cannula connected to a oxygen flow meter that was set at three liters per minute. A review of the patient's medical record showed the physician's order for oxygen, initiated on 7/5/11, was for two liters per minute to maintain an oxygen saturation of greater than 92%. (Oxygen saturation refers to amount of oxygen carried in the blood).

On 7/25/11 at 1535 hours, during an interview, RT A stated Patient 74's oxygen should be set at 2 liters per minute. RT A added the patient was checked at 1100 hours, and the oxygen saturation was 100%. When asked if he checked the oxygen flowmeter at that time, RT A did not respond.