HospitalInspections.org

Based on observations and interviews the Hospital failed to ensure: 1.) personal privacy for all patients within the Emergency Department (ED) and 2.) to all patients on the Geriatric Psychiatric Unit (GPU) that may use the public telephone.

Findings include:

The Hospital policy titled Patient Rights and Responsibilities indicated that the hospital will support the right of each patient's privacy.

1.) a.) Surveyors #2 and #3 conducted a tour of the ED at 8:05 A.M. on 7/11/13. Surveyors #2 and #3 observed three video cameras in the ED, one located in a hallway and two were in patient care rooms, #9 and #10. Surveyor #2 and #3 observed a small notice of camera surveillance use, behind the door of rooms #9 and #10.
b.) Surveyors #2 and #3 interviewed the Security Shift Supervisor on 7/11/13 during the tour of the ED. The Security Shift Supervisor said the videos were recording patient activity in rooms #9 and #10 and the videos were stored on a Digital Video Recorder (DVR) hard drive for 30 days. The Security Shift Supervisor said the monitor screens for the cameras were located in the Security Office on the fifth floor. Surveyor #3 asked Security Shift Supervisor how the Hospital afforded patient privacy during the provision of care. The Security Shift Supervisor could not explain how privacy was provided.
c.) Surveyors #2 and #3 conducted a tour of the Security Office on the fifth floor at 10:24 A.M. on 7/11/13. Surveyors #2 and #3 observed video screens that displayed live videos of ED patients in rooms #9 and #10 who were lying on stretchers.
d.) Surveyor #3 observed during the ED tour at 8:15 A.M. on 7/11/13 curtains were not pulled for patient privacy, one patient was curled up on his/her side, sleeping in full view. In the next bay, a patient was sleeping without curtains pulled for patient privacy.

2.) a. Surveyors #1, #2, and #3 conducted a tour of the GPU at 9:45 A.M. on 7/10/13. Surveyors #1, #2 and #3 observed a public telephone for patient use, on the wall in the hallway. The location of the telephone lacked privacy because hospital staff, other patients or visitors could hear personal private conversations.

Based on observations and interview, the Hospital failed to provide Patient #9 with safe care because hand hygiene (hand washing) and infection control standards were not followed by Registered Nurse (RN) #1.

Findings include:

1.) Surveyor #3 observed at 10:10 A.M. on 7/10/13, RN #1 did not wash her hands before or after administering medications to Patient #9.

2.) Surveyor #3 observed RN #1 open the Geriatric Psychiatric Unit kitchen door, enter the kitchen, leave the kitchen and return to the kitchen without washing her hands.

3.) Surveyor #3 observed RN #1 then proceed to remove medications from the automated medication dispensing system and prepare another patient's medications without washing her hands.

4.) Surveyor #3 interviewed RN #1 prior to administering the next patient's medications. RN #1 said she forgot to wash her hands. Surveyor #3 observed RN #1 wash her hands for 30 seconds without soap or alcohol and not in accordance with hand hygiene and infection control standards.

Based on observation, interview and Hospital policy the Hospital failed to ensure the confidentiality and protection of patients' electronic medical records on the Geriatric Psychiatric Unit and A6 Unit.

Findings include:

1.) Refer to A-0441 (Confidentiality of Medical Records).

Based on review of 1 of 14 medical records (Patient #9) and Hospital policy titled Pain Assessment, Reassessment & Management, the Hospital failed to assure pain assessments were performed according to Hospital policy.

Findings include:

The Hospital policy titled Pain Assessment; Reassessment & Management indicated that all patients undergo reassessment of pain at least once per shift and after pain control interventions as appropriate.

Nursing Notes, dated 7/8/13 on the day shift and 7/9/13 on the evening shift, did not indicate that a nurse assessed Patient #9 for pain according to Hospital policy.

Surveyor #3 interviewed Nurse Educator #2 at 11:30 A.M. on 7/11/13, during a Medical Record Review. Nurse Educator #2 said a nurse should do a pain assessment on each shift.

Refer to A-0449 (Content of Medical Record, 1.C.).

Based on review of 2 of 14 medical records (Patients #8 and #9), interview and the Hospital policies titled (1.) Care Planning and Patient Assessment, Reassessment and (2.) Documentation of Care, the Hospital failed to assure the patient care plans were current.

Findings include:

1.) The Hospital policy titled Care Planning indicated that the plan of care, treatment and services is individualized to meet the patient's unique needs and the plan is revised on the patient's response.

2.) The Hospital policy titled Patient Assessment, Reassessment and Documentation of Care indicated that a plan of care is developed to address care treatment and services based on the patient assessment.

The Nursing Note, dated 7/7/13 at 11:12 P.M., indicated Patient #8 was treated with antibiotics for a urinary tract infection (UTI). Patient #8's Nursing Care Plan (NCP) did not indicate his/her UTI.

A Physician Progress note (time not indicated), dated 7/11/13, indicated Patient #9 had a UTI.

The Nursing Note at 7:44 P.M. on 7/1/13 indicated Patient #9 was agitated, spitting and kicking at staff.

Patient #9's NCP did not indicate revisions or updates related to Patient #9's behavior or UTI.

Surveyor #3 interviewed Nurse Educator #1 at 10:15 A.M. on 7/11/13. Nurse Educator #1 said a nurse should have developed Patient #9's Nursing Care Plan with a problem list and interventions to reflect behavioral issues and his/her UTI.

Refer to A-0449 (Content of Medical Record, 3.A.1-3. regarding Care Planning)

Based on observation and review of the Hospital policy titled Medication Administration, the Hospital failed to assure a Registered Nurse (RN) was knowledgeable about the medications she was administering.

Findings include:

The Hospital policy titled Medication Administration, dated July 2012, indicated that before administering medication the individual who will be administering the medication is informed of educational needs regarding the medication.

Surveyor #3 observed, on 7/10/13 at 9:55, while RN #1 was preparing a patient's cardiac medications, that the medication name on the patient's medicaton administration record was different than the medication name on its package.

Surveyor #3 interviewed RN #1 at 9:55 A.M. on 7/10/13. The Surveyor asked RN #1 how she knew that the different medication names were the same drug. RN #1 said 4 grams comes from the pharmacy and I give what it says.

Surveyor #3 observed that RN #1 was not able to answer if the medications, with different names, were actually the same drug.

Based on interview and review of 2 of 14 medical records (Patients #10 and #11), the Hospital failed to administer and document blood transfusions according to standards of practice.

Findings include:

The Hospital's policy and procedure related to the administration of blood and blood components indicated an order was required to initiate a blood or blood component transfusion. The transfusion orders include a rate the nurse should administer the blood transfusion. The Transfusion Form indicated a space provided for vital signs at pre-transfusion, 15 minutes after initiation, 30 minutes after initiation and at the completion of the transfusion.

The Physician Order for Patient #10, dated 7/9/13 at 4:13 A.M., indicated that the physician ordered 2 units of packed cells transfused over four hours. Surveyor #2 could not find the transfusion record for the blood transfusion ordered in Patient #10's medical record.

Surveyor #2 interviewed the Interim Nurse Manager of the ED on 7/11/13 at 1:30 P.M. The Interim Nurse Manager of the ED said Patient #10's transfusion record was not in Patient #10's medical record because she had the transfusion record in her possession for quality monitoring related to documentation of blood transfusions. The Interim Nurse Manager of the ED said she would place Patient #10's transfusion record into Patient #10's medical record.

Patient #10's transfusion record, dated 7/9/13, indicated the nurse started the first unit of packed cells at 6:16 A.M. The staff did not document vital signs after 30 minutes following the initiation of the transfusion; also, staff documented the transfusion completed at 9:00 A.M., 2 hours 45 minutes not over 4 hours as ordered. In addition, there was no transfusion record for the second unit of blood that the physician ordered.

The Physician Order for Patient #11 dated 7/8/13 at 10:57 P.M., indicated to transfuse Patient #11 with two units of packed cells over four hours.

The transfusion form, dated 7/9/13 for Patient #11 indicated staff started a transfusion at 4:20 A.M. and the transfusion completed at 7:00 A.M., 2 hours 40 minutes not four hours as ordered.

A blood bank query, performed 7/11/13 for Patient #11 indicated the blood bank released two units of blood on 7/9/13 for Patient #11. Patient #11's medical record indicated only one transfusion record; the second transfusion record could not be located.

Based on observations, interview and Hospital policy titled Patient's Rights and Responsibilities, the Hospital failed to ensure: (1.) Confidentiality and protection of patients' electronic medical records on the Geriatric Psychiatric Unit and A6 Unit and (2.) Prevent the potential for medical record water damage in the Medical Records Department.

Findings include:

1) The Hospital policy titled Patient's Rights and Responsibilities, dated July 2012, indicated that the patient has the right to confidentiality of his/her medical information.

During a medical record review conducted in the nursing station area of the Geriatric Psychiatric Unit, in the presence of Nurse Educator #1, on 7/11/13 at 12:15 P.M., Surveyor #1 observed three unattended computers. Surveyor #1 easily visualized patient medical record information on the computers. Surveyor #1 observed two of the three computers were unattended after 9 minutes and one computer remained unattended after 29 minutes.

Surveyor #1 interviewed Nurse Educator #1 on 7/11/13 at 12:15 P.M. Nurse Educator #1 said the computers should not be left unattended.

Surveyor #1 observed on 7/15/13 at 8:50 A.M., on the A6 Unit, patient information on an unattended computer screen.

Surveyor #1 interviewed the RN #2. RN #2 said she knew the computer should not be left unattended, with patient information visible.

2.) Refer to A-0701 (Physical Plant #1 regarding potential medical record water damage).

Based on review of 5 of 14 medical records (Patients #1, #6, #8, #9 and #14) and Hospital policies titled (1) Medical Record Content & Documentation, (2) Master Treatment Plan and (3) Care Planning, the Hospital failed to ensure these records contained:
-identification information,
-entries dated, timed and signed by the individual making the entry,
-the Master Treatment Plan that included medical problem(s) and
-the nursing care plan that was updated.

Findings include:

1.) The Hospital policy titled Medical Record Content and Documentation, dated June 2012, indicated that the Hospital maintains a complete and accurate medical record with,

(A.) Identification information,

(B.) entries are dated, timed and signed by the individual who made the entry and

(C) information/documentation regarding evaluations.

1.) The Progress Note, dated 11/15/12 at 8:10 A.M., contained in Patient #1's medical record, did not contain patient identification (name or medical record number).

The Master Treatment Plan form, contained in the medical records for Patients #6 and #14 did not contain patient identification.

The Master Treatment Plan form contained in medical records for Patients #6 and #14 did not contain patient identification.

The Team Members form contained in the medical records for Patients #6 and #14 did not contain patient identification.

The Master Treatment Plan Outcome Measures form in the medical records for Patients #6 and #14 did not contain provider signatures.

The Treatment Plan form contained the medical records for Patients #6 and #14 did not contain provider entry signature(s).

The Master Treatment Plan contained in the medical records for Patients #6 and #14 did not contain date or time of entry or provider entry signature.

The Psychosis Problem Worksheet form in the medical records for Patients #6 and #14 did not contain date or time of provider entry.

Nursing Notes, dated 7/8/13 on the day shift and 7/9/13 on the evening shift, did not indicated that a nurse assessed or documented Patient #9's pain.


2.) The Hospital policy titled Master Treatment Plan, dated 10/11, indicated that the plan will reflect the problems requiring admission, other problems (medical and behavioral) requiring treatment, diagnoses, behavioral goals, interventions for each discipline and a discharge plan.

The Master Treatment Plan form contained in Patient #14's medical record did not contain active medical problems as required by Hospital policy.

3.) The Hospital policy titled Care Planning indicated that the plan of care, treatment and services is individualized to meet the patient's unique needs and the plan is revised on the patient's response.

The Nurses Note, dated 7/7/13 at 11:12 P.M., indicated Patient #8 was treated with antibiotics for a urinary tract infection (UTI) and his/her Nursing Care Plan (NCP) did not indicate his/her UTI.

A Physician Progress Note, dated 7/11/13 (time not indicated), indicated Patient #9 had a urinary tract infection (UTI) and a Nursing Note, dated 7/11/13 at 7:44 P.M., indicated Patient #9 was agitated, spitting and kicking at staff. Patient #9's NCP did not indicate revisions or updates related to his/her behavior or UTI.

Based on observations, review of the document titled Environment of Care Inspection and interviews, the Hospital failed to ensure (1) the prevention of possible medical record physical damage and (2) the removal of all potential hazards to patients from the Geriatric Psychiatric Unit (GPU) and the A6 Unit.

Findings included:

1.) Surveyor #1 observed, on 7/11/13 at 8:15 A.M., a pipe draining water in the Medical Records Department. The pipe drained water from the ceiling to a basin with a drain in the floor. Surveyor #1 heard flowing water on entrance to the Department.

The Surveyor observed the pipe with flowing water was in close proximity to patient medical records.

The Surveyor interviewed File Clerk #1, on 7/11/13 at 8:15 A.M. File Clerk #1 said she did not know the reason for the pipe that drained water.

The document titled Environment of Care Inspection of the Medical Record Department, dated 2/7/13 and completed by the Department Manager, did not indicate an intervention to manage the possibility of medical record damage from water.

The Surveyor interviewed the Hospital President on 7/11/13 at approximately 11:20 A.M. The Hospital President said that the pipe draining water was part of the Hospital heating and cooling system and that the pipe could not be removed or occluded. The Hospital President said the Hospital was securing the pipe an enclosure that would separate the pipe from patient medical records.

2.) During a Tour of the Geriatric Psychiatric Unit, on 7/10/13 at 2:10 P.M., Surveyors #1, #2 and #3 observed:

-Collapsible metal hooks affixed to bathroom walls in six patient rooms. When the hooks were not in the collapsible position, the hook protruded outwards and provided a risk for patient injury or self inflicted wound;
-Bed alarm cords attached to five patient beds, which were of length that provided a risk of patient injury or suicide; and
-In room 104, exposed wood on the sink cabinet and 2 pieces of adhesive tape used to close the sink cabinet door. The sink cabinet with exposed wood created a surface that could not be properly cleaned.

The Surveyors observed in room 119, peeling paint in the shower room stall, a dent compromising the integrity of the wall behind the head of the bed in the room, the toilet paper holder contained 2 exposed metal hinge like devices that posed potential risk for injury. The Surveyor observed a closet plastic bar and the plastic bar contained several clothes hooks; the first plastic hook was broken with no clear breakaway of the devise assuring patient safety.

The Surveyors observed a window blind cord draping down from its track in room #117 that provided a risk for patient injury.

The Hospital President, the Director of Quality and Regulatory and the Chief Operating Officer interviewed in person on 7/10/13 during the second tour. The President, the Director of Quality and Regulatory and the Chief Operating Officer and they acknowledged the Surveyors' findings regarding the safety issues found during the first tour on 7/10/13.

Surveyor #1 observed, on the A6 Unit, on 7/15/13 at 8:15 A.M., a patient backboard (board used to assist moving a patient from a bed to a stretcher) was not secured to the wall presenting the potential to fall from its placement on the wall railing and injure a patient.