HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failing to perform daily weights as ordered by the physician for 3 of 3 patient records reviewed for daily weights in a total sample of 30 (Patient #3, 10, 24).
Findings:

Patient #3
Review of the medical record for Patient #3 revealed an admit date of 04/24/19. Review of the admit physician orders revealed an order to obtain daily weights.

Further review of the medical record revealed daily weights were not obtained on the following dates: 5/25/19, 5/21/19, 5/17/19, 5/18/19, 5/13/19, 5/14/19, 5/16/19, 5/12/19.

On 05/29/19 at 10:50 a.m., S2DOQM reviewed the patient's record and confirmed that daily weights were not obtained as ordered.

Patient #10
Review of the medical record for Patient #10 revealed an admit date of 04/12/19. Review of the admit physician orders revealed an order to obtain daily weights.

Further review of the medical record revealed daily weights were not obtained on the following dates: 5/27/19, 5/23/19, 5/21/19, 5/18/19, 5/17/19.

On 05/29/19 at 11:20 a.m., S2DOQM reviewed the patient's record and confirmed that daily weights were not obtained as ordered.

Patient #24
Review of the medical record for Patient #24 revealed an admit date of 05/24/19. Review of the admit physician orders revealed an order to obtain daily weights.

Further review of the medical record revealed daily weights were not obtained on the following dates: 5/30/19, 5/29/19, 5/28/19, 5/27/19, 5/26/19, 5/25.

Based on record review and interview, the hospital failed to ensure all drugs and biologicals were administered as ordered by the physician and according to acceptable standards of practice for for 2 (#3, #10) of 10 medical records reviewed for medication administration from a total sample of 30 patient records.
Findings:

Patient #3
Review of Patient #3's physician orders dated 05/20/19 at 2300 revealed an order for Dilaudid 1-2mg intravenous every four hours as needed for moderate pain.

Review of the nurses notes dated 05/20/19 at 2330 revealed "complained of pain left knee, 7/10 on 0/10 scale, PRN given". There was no documentation of what dosage of the Dilaudid medication was administered. Review of the MAR dated 05/20/19 at 2330 revealed no documentation that any pain medication was administered.

Review of the MAR dated 05/24/19 at 0950 revealed Dilaudid 2mg intravenous was administered.

Review of the MAR dated 05/27/19 at 0125 and 1400 revealed Dilaudid 1mg intravenous was administered.

On 05/29/19 at 10:50 a.m., interview with S2DOQM confirmed that the physician order to administer a range of 1-2mg of Dilaudid should have been clarified by the nursing staff.


Patient #10
Review of Patient #10's physician orders revealed an order dated 05/02/19 at 0908 for Levophed with the following parameters:
Initial dose, 0.01 mcg/kg/min
Incremental dose 0.01mcg
Time interval q15 min and prn
Max dose/rate 0.17 mcg/kg/min
Pt goal MAP >60

Review of Patient #10's Critical Care Flowsheet revealed the Levophed infusion had been titrated as follows:
05/02/19
0915 - initiated at 0.01mcg/min
0930 - 0.02mcg/min, MAP (50)
0945 - 0.04mcg/min, MAP (59)
1000 - 0.02mcg/min, MAP (93)
1130 - 0.01mcg/min, MAP (89)
1500 - infusion stopped, MAP (91)
1615 - 0.01mcg/min, MAP (60)
1715 - infusion stopped, MAP (85)
1915 - 0.01mcg/min, MAP (44)
Further review of the flowsheet revealed the patient's MAP was (30) at 1300, (53) at 1515 and (53) at 1830 with no documented titrations at these times.
There was no further documentation on the flowsheet indicating any further titrations.

Review of the nurses notes dated 05/03/19 at 0600 revealed "stopped Levo". Further review of the nurses notes dated 05/07/19 at 1015 revealed "Levophed started at 0.01mcg/min due to MAP <60".

On 05/29/19 at 12:05 p.m., S3CNO reviewed the patient's record and confirmed that the Levophed was not administered and titrated per physician orders. Further interview confirmed that the staff stopped and restarted the Levophed without a physician's order.

Based on observation and interview, the hospital failed to ensure that medical records were properly filed and retained as evidenced by failure to ensure that all medical records were protected from potential water damage if the hospital's sprinkler system became activated.
Findings:

On 05/28/19 at 2:00 p.m., observation of the medical records room with S5Medical Records Director revealed approximately 1,000 paper medical records stored on open shelves. Further observations revealed sprinkler heads in the ceiling. At that time, interview with S5Medical Records Director revealed that discharged patient records for the past eight months were stored on the open shelves and they were not protected from water damage should the sprinkler system activate.

Based on record review, observation and interview, the hospital failed to ensure the accurate disposition of all scheduled drugs as evidenced by a nurse failing to have a witness when wasting scheduled medication.
Findings:

Review of the policy titled, Automated Dispensing - Returns, revealed in part that the wasting of controlled substance medication must be observed by two nurses and documented by the same two nurses.

On 05/28/19 at 10:10 a.m., observation revealed S4RN was in the medication room preparing medication in a syringe for Patient #1. Further observations revealed S4RN withdrew 0.75mL of Dilaudid 2mg from a 1mL vial. After preparing the medication, S4RN was observed to discard the Dilaudid vial containing medication into the sharps container. There was no witness to the disposition/waste of the discarded Dilaudid medication.

On 05/28/19 at 10:50 a.m., interview with S4RN confirmed that Patient #1 had a current physician order for Dilaudid 1.5mg intravenous as needed every two hours. Further interview revealed that 0.25mL of Dilaudid is wasted every time the patient receives the medication. When asked what staff member witnessed the Dilaudid waste during the above observation, S4RN stated that S8RN had witnessed it. When informed that S8RN was not in the medication room when the Dilaudid medication was disposed of, S4RN confirmed that she was not. S4RN further stated that S8RN had documented that she had observed the waste of the Dilaudid when it was originally removed from the automated medication dispensing unit. When asked if this was her usual procedure for wasting scheduled medications, she stated yes.

On 05/30/19 at 2:25 p.m., S2DOQM confirmed that the wasting of controlled medication must be observed by two nurses.

Based on record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's chart for 2 (#12, #27) of 2 patient records reviewed who had hospital identified medication errors.
Findings:

Patient #12
Review of hospital incident reports and Patient #12's medical record revealed on 04/27/19 at 10:30 p.m. that TOBI (Tobramycin) inhalation twice daily had been ordered. Further review revealed the first dose of Tobi was not started until 04/29/19 at 11:00 a.m. Further review revealed no documentation of the medication error or that the physician had been notified of the medication error. On 05/30/19 at 2:00 p.m., S7RRT reviewed the patient's record and confirmed there was no documented evidence that the medication error was noted in the record or that the physician was notified of the error.

Patient #27
Review of hospital incident reports and Patient #27's medical record revealed on 03/09/19 that Vancomycin 1gm intravenous was ordered times one. Further review of the incident report revealed that Rocephin was administered instead of the Vancomycin. Review of the medical record revealed no documentation of the medication error or that the physician had been notified of the error.

Based on contract review, organizational chart review, and interview, the hospital failed to ensure Radiological Services were under the direction of a Radiologist. This deficient practice is evidenced by failure of the Governing Body to appoint a Radiologist to serve as Director of the hospital's contracted Radiological Services.
Findings:

Review of the hospital's contracts revealed a contract with Hospital A to provide radiology services.

Review of the hospital's organizational chart revealed no documented evidence of an appointed Radiologist to serve as Director of the hospital's contracted Radiological Services.

In an interview on 05/29/19 at 2:00 p.m. with S2DOQM, he confirmed the hospital's on location x-ray services were provided via contract with Hospital A. S2DOQM further confirmed the hospital's Governing Body had not appointed a radiologist to serve as the Director of the hospital's contracted Radiological Services.

Based on record review, observation and interview, the hospital failed to maintain a system for controlling infections and communicable diseases as evidenced by: 1) failing to appropriately clean patients rooms after discharge, 2) failing to disinfect the septum of a medication vial prior to inserting the needle to withdraw medicine for 1 of 1 nurse observed during medication preparation (S4RN) and 3) failing to properly disinfect patient equipment after use.
Findings:

1) Failing to appropriately clean patients rooms after discharge

On 05/28/2019 at 09:50 a.m., observation of room a, designated as clean by S1COO, revealed an old electrode lead was stuck to the front of the nurse call bell/television remote. Further observation revealed rips/tears to the upholstery of the arm chair and sleeper sofa which prevents proper disinfection of the furniture.

During an interview on 05/28/2019 at 09:55 a.m., S1COO who accompanied surveyor during the observation acknowledged the findings.

2) Failing to disinfect the septum of a medication vial prior to inserting the needle to withdraw medicine for 1 of 1 nurse observed during medication preparation (S4RN)

Review of the CDC's "Safe Practices for Medical Injections" revealed in part that the rubber septum of medication vials should be disinfected with alcohol prior to piercing it.

On 05/28/19 at 10:10 a.m., observations of S4RN preparing intravenous medications revealed that S4RN inserted the needle into the medication vials of Dilaudid and Phenergan without first disinfecting the septums with alcohol.

On 05/30/19 at 2:30 p.m., interview with S3CNO confirmed that the septums on the medication vials should be disinfected with alcohol prior to needle insertion.

3) Failing to properly disinfect patient equipment after use

On 05/29/2019 at 08:00 a.m., observation of room b revealed the following:
a. tilt table had rips/tears to the vinyl covering which prevents proper disinfection and a thick layer of grime on the visible upper and lower framework. The tilt table had a plastic green "clean" marker placed on the table indicating it was clean.
b. exam table had hair and grime on the top surface. The exam table had a plastic green "clean" marker placed on the table indicating it was clean.
c. vital signs machine had a thick layer of grime on the visible surfaces of the pedestal.

During an interview on 05/29/2019 at 08:10 a.m., S3CNO, who accompanied surveyor during the observation, acknowledged the equipment designated as clean was not properly disinfected.

On 05/29/2019 at 08:20 a.m., observation of room c revealed the following:
a. 3 of 8 feeding pumps with grime on the pump's visible surfaces.
b. 4 of 4 intravenous infusion pumps with grime on the pump's visible surfaces.
c. pulse oximeter cable with old tape stuck around the wire.

During an interview on 05/29/2019 at 08:25 a.m., S3CNO, who accompanied surveyor during the observation, acknowledged the equipment designated as clean was not properly disinfected.