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Based on review of the clinical record and interview, for one (Pt. #24) of two records reviewed in short stay PACU (post anesthesia care unit), the hospital failed to ensure that the patient's respiratory status/oxygenation post-surgery was documented. The finding includes:
Review of the surgical record for Patient #24, identified that on 11/1/11, the patient underwent a left total ethmoidectomy and a left maxillary antrostomy with drainage of a submucosal mucus pyocele. The patient left the operating room wearing a 35% oxygen mask and arrived in short stay PACU at 8:35 AM, alert and oriented with an oxygen saturation of 100%. Review of PACU nursing documentation reflected that although the patient's vital signs (including oxygen saturation) were taken every fifteen (15) minutes times three (3), the documentation failed to reflect when the patient's supplemental oxygen was discontinued prior to being discharged at 10:15 AM at the patient's request. The record reflected that until 9:15 AM, the patient's oxygen saturation remained at 100%. During interview on 11/1/11, the Charge Nurse stated that cold steam would have been delivered to the patient during the stay in the PACU based on a verbal order from the surgeon, however, the surgical record failed to reflect such an order or when the supplemental oxygen was discontinued.



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Based on review of the clinical record and policy review, the facility failed to ensure that a patient's level of pain was monitored following administration of pain medications. The findings include the following:

Patient #51 was admitted for the placement of a dorsal column stimulator. Review of the PACU record for Patient #51 indicated that the patient was admitted to PACU at 4:09 PM. Review of the PACU orders directed Fentanyl 25 mcg IV as needed for pain once and can repeat 3 times for a maximum of 100 mcg. The note identfied that at 4:56 PM, the patient was more awake and complained of severe pain from the lower back down. Review of the PACU flow sheet reflected that the patient received Fentanyl at 4:35 PM, 4:45 PM, and 4:55 PM for a pain level of 10 of 10 (scale of 1-10 with 10 being the worst possible pain). The record failed to contain an assessment for the efficacy of the medication. The patient also received a dose at 5:10 PM the record lacked a pain score and/or a reassessment for the efficacy of the medication.

Review of the facility policy indicated that pain should be assessed within 30 minutes of as needed parenteral analgesics





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Based on review of the clinical record, review of facility policies, observations, and interview, the facility failed to ensure that preventive measures were consistently implemented for two of four patients, Patients #28 and #63, who were at high risk to develop pressure ulcers and or who subsequently developed a facility acquired pressure ulcer. The findings include:

1. Patient #28 was admitted to the facility on 10/27/11 with diagnoses that included sepsis as a result of a urinary tract infection. The admission nursing assessment dated 10/27/11 included a Braden Scale score of fourteen (14) that identified Patient #28 as at high risk to develop pressure ulcers. A nursing care plan dated 10/27/11 identified Patient #28's risk for skin impairment with interventions that included the use of heel protectors in bed. During a tour of the SLA 4 unit with facility staff on 11/1/11 at 9:35 AM identified that Patient #28 was in bed, lying on his/her back, and that a pair of heel protectors were on the bedside chair. A second observation on 11/1/11 at 9:50 AM identified that although Patient #28's bilateral heels remained intact, the heel protectors were reapplied only after surveyor inquiry.

2. Patient #63 was admitted to the facility on 10/19/11 with diagnoses that included an acute left femur fracture. The admission nursing assessment identified that Patient #63 entered the facility without a pressure ulcer. An admission Braden Scale score of fifteen (15) identified that Patient #63 was at high risk to develop pressure ulcers. Although a nursing care plan dated 10/19/11 identified Patient #63's risk for skin impairment, the care plan lacked documentation to reflect interventions to protect the patient's heels from skin impairment due to pressure. Review of the clinical record dated 10/29/11 identified that Patient #63 developed a Deep Tissue Injury (DTI) pressure ulcer on the right heel and that heel protectors were placed at that time. Observation of Patient #63 on 11/1/11 at 10:40 AM identified that although bilateral heel protectors were in place, the heel protectors used did not provide pressure relief. Patient #63 was evaluated by the facility's Wound Care team on 11/1/11 and identified to have a 1.0 by 1.0 centimeter (cm.) DTI on the right heel. Interview with Wound Care Nurse #1 on 11/2/11 at 1:15 PM identified that facility policy directed that patients at risk for impaired skin integrity at the heels would require the heels to be offloaded to prevent pressure. Wound Care Nurse #1 stated that the heel protectors described as observed on Patient #63 on 11/1/11 were not considered a pressure relieving intervention.

Based on a review of clinical records and policy review, the facility failed to ensure that two patient's (#41 and #44) had comprehensive and/or individualized treatment plans to meet the needs of the patient. The findings include the following:

a. Patient #41 was admitted on 10/28/11 and had a cesarean section completed. Review of the clinical record for Patient #41 indicated that the patient had a history of drug use and tested positive for drugs on admission. The chart indicated that DCF and Social Services was involved. Review of the care plan indicated that the patient's active problems were identified as isolation and post-partum care. The care plan failed to identify that the patient's psychosocial issues had been addressed.


b. Patient #44 was admitted with suicide attempt and pain secondary to chronic arthritis. Review of the treatment plan indicated that the patient's active problems were depression, pain management, psychosocial problems, behavioral problems and functional/rehabilitation problems. Review of the treatment plan failed to identify active interventions for the rehabilitation problems. In addition the treatment plan identified that the patient should attend level 2 and 3 groups. The treatment plan failed to be individualized and identify specific groups the met the needs of the patient.

Review of the facility policy indicated that the care plan should be reviewed and revised on a daily basis.

Based on clinical record reviews, review of hospital policies and procedures and interviews with facility personnel for ten of ten sampled patients (Patient #53, #77, #78, #79, #80, #81, #82, #83, #84 and #85), the facility failed to ensure that consents were timed. The findings include:

Review of consents for radiation therapy for Patients #53, #77, #78, #79, #80, #81, #82, #83, #84 and #85 failed to reflect that the consents were timed. Review of hospital policy identified that all consents are to be dated and timed. Interview with the Quality Coordinator on 11/8/11 identified that hospital policy is that all consents are to be timed.

Based on observation and interview, the hospital failed to ensure that a system was in place to store neuromuscular blocking medications in the GI clinic. The finding includes the following:

a. During tour of the GI Clinic on 11/2/11 with a Quality Representative and the Clinic Manager, a review of the locked stock closet identified a storage bin that contained syringes of neuromuscular blocking agents including succinylcholine and rocuronium among the anesthesia supplies. During interview on 11/2/11, the anesthesiologist who was responsible for oversight in the clinic stated he was unaware of the medications in the closet however would take measures to secure the medications. During interview on 11/7/11, the Pharmacy Assistant Director stated that the medications should be contained in a locked anesthesia medication cart.

In the Radiology Department, one item of non-compliance was identified within the scope of the inspection on November 15, 2011. The finding includes:
Sec. 19-24-6 in part requires that each owner of an installation or mobile source shall supply appropriate personnel monitoring equipment to and shall require the use of such equipment. Additionally, each owner shall maintain records showing the radiation exposures of all individuals for whom personnel monitoring is required.
Contrary to the above, Hospital of Saint Raphael's failed to ensure operating room staff wore their dosimetry for 2011.

Based on review of facility policies, observations, and interview, the facility failed to ensure that the code cart on the Children's Day hospital was regularly checked to ensure that all emergency equipment would be available in the case of an emergency. The findings include:

1. During a tour of the Children's Day Hospital on 11/2/11 at 10:30 AM, the daily check log of the unit's emergency code cart was reviewed. The documentation identified that the cart had not been checked since 8/24/11. Observation of the cart's contents identified that emergency equipment listed as available was missing and included the lack of a backboard, lack of a rebreather mask, and lack of nasal cannulas. Interview with the Director of the unit at the time of the observation identified that the unit secretary was responsible for checking the cart daily, documenting that the check had been done, and reporting of any missing contents. The Director stated that at the time of the observation, there was no system in place to routinely oversee that the checks had been done. Facility policy directed that the cart be checked daily on all days of operation of the unit.



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2. Based on a tour of the hospital and staff interview, the facility failed to ensure that the psychiatric care sleeping rooms and units were maintained in such a manner as to promote the safety and well-being of patients.
On 11/02/11 at 10:30AM and at other times throughout the survey, while touring the adult psychiatric units with the Engineering and Facility Administration the following was observed:
a. The faucet and shower controls, door handles, door hinges, paper towel dispensers, toilet paper dispensers, liquid soap dispensers were not designed to a psychiatric/ institutional standard and subsequent interview indicated that a current risk based analysis by the facility prior to this inspection had not been completed but was underway
b. The facility had installed an air conditioner in Celantano 1, room 17 that had a long electrical cord that posed a hanging hazard.

Based on observation during tour, the facility failed to ensure that supplies, and equipment was maintained to ensure an acceptable level of safety and quality. The findings include the following:

a. Tour of the OB/GYN operating rooms identified torn and ripped OR pads in OR #2. Surgical items that had been terminally sterilized were placed on top of the dirty linen hamper in OR #1.


b. On 11/02/11 at 1:30 PM, the surveyor while accompanied by the Security Operation Manager, the Department of Engineering and Maintenance Operations Manager, the Utility Manager and the Dietary Manager observed the following:

1. Tour of emergency supply storage area in the Utility Manager Office identified 6 cans of TWO CAL HN with an expiration date of July 2011.

2. Tour of the kitchen supply area identified 5 cases of tube feed, TWO CAL HN with expiration dates of July 2011 and August 2011.

Based on observation, interview and review of hospital policy, the hospital failed to ensure that infection control practices were followed. The findings include the following:
a. During tour of the Operating Suites on 11/1/11, one staff member was observed to wear a hair covering that failed to include the hair along the back of his head. Additional observations identified several staff members wearing earrings outside the cover of the head bonnet. According to hospital policy, all hair should be covered/confined and jewelry should be removed or confined when personnel are within the semi-restricted and restricted areas of the surgical suite.

b. Observation of a hand table utilized in Core II identified that the pad was held to the table with strips of adhesive tape that failed to be removed and reapplied between patients.

c. Several Operating Rooms throughout the suite were observed to have desks cluttered with miscellaneous office supplies/equipment/papers that were present from case to case. According to hospital policy, terminal cleaning of the OR included the cleaning of all horizontal surfaces of the equipment/furniture in the OR daily and between cases.

d. Review of the biological testing log for the three sterrad machines in Central Sterile on 11/1/11, identified that on 10/15/11, the biological test either was not completed and/or not documented as done (the log was blank). Additionally, on 10/7, 10/10, 10/17 and 10/31/11, the biological test was read prior to the required 24 hours required by the manufacturer's directions to achieve an accurate initial test result. During interview on 11/1/11, the manager of Central Sterile stated that he was aware just that morning of an early read and routinely utilized the quality personnel for his unit to review the biological log. Review of the hospital policy, a biological test for sterrad is completed initially at 24 hours with a final read at 48 hours.

e. Observation during tour of the outpatient clinics on 11/2/11 with a Quality Representative and Nurse Manager, identified that the procedure room and the laser room contained stools and/or chairs with ripped and/or split upholstery, exposing the inner fabric. Additionally, the metal cast stand was rusted, prohibiting the facility to adequately clean the equipment between patients.



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f. Patient #29 was admitted to the facility on 10/30/11 with diagnoses that included bilateral leg cellulitis. The clinical record dated 10/31/11 identified that Patient #29 was diagnosed with Methicillin Resistant Staphylococcus Aureus (MRSA) based on a nasal culture obtained upon admission. Patient #29 was subsequently placed on contact precautions in accordance with facility policies. During a tour of the SLA 4 unit with facility staff on 11/1/11 at 10:00 AM, a volunteer was observed in Patient #29's room without the benefit of a protective gown and/or gloves. The volunteer was observed to make contact with multiple items with Patient #29's room including the patient's overbed table, and bed linens. The volunteer was further observed to pat the shoulder of the patient and subsequent shake hands with the patient before exiting the room. Interview with the volunteer at the time to the observation identified that although he/she had seen the posted signage, he/she stated that the patient was going home that day so that he/she didn't think the precautions were really necessary. Review of facility documentation identified that the facility had an orientation program in place for volunteers at the hospital that included education regarding contact precautions. Review of facility policy directed that anyone entering the room of a patient on contact precautions must wear a protective gown and gloves upon entering the room.



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g. During a tour of the Coronary Intensive Care Unit, CCU, on 11/1/11 from 1:48 P.M. to 2:30 P.M., with the Nursing Director of the Intensive Care Units and the Nurse Manager of the unit, RN #13 was observed to exit a patient's room garbed in personal protective equipment inclusive of a gown, mask and gloves. RN#13 rummaged through a box of medical supplies in the hallway and re-entered the patient room. The Nurse Manager identified that the patient was on contact isolation for a resistant organism. The Nurse Director identified that this practice was not acceptable and talked with RN #13. RN #13 was then observed to again exit the patient's room to rummage through a box of medical supplies in the hallway and re-entered the patient room while garbed in personal protective equipment. The Nurse Manager identified that this practice was not acceptable and talked with RN #13. Interview with Nurse Manger #5, on 11/7/11 at 2:11 P.M., identified that RN #13 was removed from caring for the patient on 11/1/11 and re-educated on proper hand washing, contact precautions and use of personal protective equipment prior to providing direct patient care.

Based on review of the clinical record for one of four patients (#73) reviewed, the hospital failed to ensure that the history and physical (H&P) was completed in a timely manner. The finding includes the following:

a. Patient #73 underwent a panendoscopy and colonoscopy on 11/2/11. Review of the clinical record identified that the H&P was dated 9/27/11. Review of the medical staff bylaw Rules and Regulations identified that the H&P must be within 30 days prior to an invasive procedure.

Based on review of the clinical record, for four (4) of four (4) patient's (#70, 71, 72, and 73), the hospital failed to ensure that the Anesthesia post-assessment reflected the time of the assessment. The findings include:

a. Patient #70 underwent a pan endoscopy and colonoscopy on 11/2/11 with monitored sedation (propofol). Review of the clinical record failed to identify a timed post anesthesia evaluation completed prior to the patient's discharge.

b. Patient #71 underwent a colonoscopy on 11/2/11 with monitored sedation. Review of the clinical record failed to reflect that a timed post anesthesia evaluation was completed prior to the patient's discharge.

c. Patient #72 underwent a colonoscopy on 11/2/11 with monitored sedation. Review of the clinical record failed to reflect that a timed post anesthesia evaluation was completed prior to the patient's discharge.

d. Patient #73 underwent a panendoscopy and colonoscopy on 11/2/11 with monitored sedation. Review of the clinical record failed to reflect that a timed post anesthesia evaluation was completed prior to the patient's discharge.
Review of the medical staff bylaw Rules and Regulations identified that all clinical record entries should be timed.

Based on observation, interviews and review of hospital policy and procedure for one of two patients (Patient #58) that required care and services in the Emergency Department, the hospital failed to ensure that personal cell phone use was prohibited in accordance with hospital policy. The findings include:
During a tour of the Emergency Department (ED) on 11/2/11 from 1:10 P.M. to 2:30 P.M., with the Nurse Director and the Nurse Manager, it was observed that Patient #58 was using his/her personal cellular telephone while connected to medical equipment, a cardiac monitor, in a multiple patient room. Interview with Patient #58, on 11/2/11 at 1:40 P.M., identified that he/she was using his/her personal cellular telephone to inform his/her family of his/her ED stay. Interview with the Director of Information Services, on 11/4/11 at 2:12 P.M., identified that the current policy is that use of a personal cellular telephone in the ED is prohibited. Review of the hospital policy and procedure, titled Use of Cellular telephones and Two Way Radios, E-60, identified that cell phone use by patients who are connected to medical equipment is prohibited. Review of the hospital document, titled " Welcome to the ED " , it identified that cell telephones may not be used by patients or visitors in treatment areas as they may interfere with medical equipment.