HospitalInspections.org

Based on medical record review, document review, and interview the facility failed to ensure a comprehensive nursing care plan was developed for patients for one (#13) of thirty-five patients reviewed.

The findings included:

Patient #13 was admitted to the facility on February 24, 2010, with diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Gastroesophageal Reflux Disease, Chronic Pain, Non-healing Wound of Left Lower Extremity. Review of the Medication Administration Record revealed this patient received Lorcet 10/325 mg (milligrams) four times on February 24, 2010; four times on February 25, 2010; four times on February 26, 2010; five times on February 27, 2010, and three times on February 28, 2010. Review of the Nursing Care Plan revealed the issues of comfort and pain control were not addressed.

Interview with the Case Manager on March 2, 2010, at 8:50 a.m., on the Medical Unit confirmed the nursing care plan did not address the patient's pain and comfort concerns.

Based on observation, review of manufacturer's instructions, facility policy review, and interview, the facility failed to assure drugs and biological were properly stored and not available for patient use when expired.

The findings included:

Observation in the entrance hall of the OR (operating room) on March 1, 2010, at 10:50 a.m., revealed a portable suction machine with approximately 2 dozen vacurette curetts (devices used internally on a patient in the performance of dilatation and curettage) without an expiration date present on the wrapper.

Review of a memo from the manufacturer, dated March 2, 2010, revealed "...Each vacurette should have a lot number and date information..."

Interview in the conference room with the Quality Assurance Director on March 2, 2010, at 4:00 p.m., confirmed the vacurette curettes available for patient use had no date and would be considered expired.

Observation in OR number 2 on March 1, 2010, at 1:35 p.m., revealed sutures available for patient use which had no expiration date.

Review of the manufacture's memo, dated December 2009, revealed "...if you have sutures in your inventory that do not have an expiration date on the packaging, this product was manufactured prior to 1998 and is considered expired..."

Interview in the conference room with the Director of Quality on March 3, 2010, at 10:10 a.m., confirmed the expired sutures were available for patient use.

Observation of an enclosed steel cabinet in the OR core with the Director of the OR on March 1, 2010, at 2:05 p.m., revealed six 500 ml plastic bottles containing (named) provadine/betadine/iodine stain remover located on an upper shelf. Continued observation revealed two sterile cloth wrapped caesarean section trays located on a lower shelf of the enclosed cabinet and available for patient use.

Review of the MSDS (Material Safety Data Sheet) for the named product revealed "...Use gloves and usual precautions for chemicals..."

Review of the facility policy Chemical Storage, revealed "...Physical aspects of the storage area...the area shall be constructed of an impervious and smooth material that can be easily cleaned..."

Interview in the OR core with the Director of OR on March 1, 2010, at 2:05 p.m., confirmed chemicals are not to be stored with sterile supplies.

Observation of the clean storage closet at the Labor and Deliver (L&D) nurse's station with the Director of the L&D on March 1, 2010, at 3:35 p.m., revealed six blue top vacutainers (tube for the collection of blood which contains a chemical preservative) with an expiration date of January 2010.

Interview at the clean storage closet of the L&D nurse's station with the Director of L&D on March 1, 2010, at 3:35 p.m., confirmed the vaccutainers were available for patient use and had expired.

Observation of the Medication Room on the Medical/Surgical Unit on March 1, 2010, at 1:30 p.m., revealed a twin pack of 0.9% Normal Saline 100 ml (milliliters) for intravenous infusion was dated with an expiration date of February 2010.

Interview with the Case Manager on March 1, 2010, at 1:50 p.m., in the Medication Room, confirmed the twin pack of 0.9% Normal Saline was expired and available for patient use.

Based on medical record review, review of Medical Staff Rules and Regulations, and interview, the facility failed to assure Verbal Orders were signed within the required time frame for one (#7) patient record of thirty-five records reviewed.

The findings included:

Patient #7 was admitted to the facility on November 22, 2009, with diagnoses to include Hydantonin Derivative (anticonvulsant medication) Poisoning, Suicidal Ideation, and Depressive Disorder. Medical record review revealed Physician's Telephone Orders as follows:

November 22, 2009, at 6:30 a.m. - "... 1/2 NS (normal saline) at 100 ml (milliliters) hr (hour)...Place on regular diet...Place on fall precautions...May have BSC (bed side commode)...Place on telemetry (cardiac monitoring)...V/S (vital signs) q (every) 2 hrs...Consult Crisis Center...CBC (complete blood count) and CMP (complete metabolic panel) at noon today...make pt (patient) observation (monitoring status)..."

November 22, 2009, at 3:00 p.m. - "...discontinue restraints when able...Haldol (major tranquilizer) 2 mg (milligrams) IM (intramuscular injection)...Benadryl (antihistamine) 25 mg IM X1 (times one) NOW..."

November 22, 2009, at 3:41 p.m. - "...Stat (immediately) Dilantin (anticonvulsant) level..."

November 22, 2009, at 4:54 p.m. - "...1/2 NS at 125 ml hr...Dilantin level at 6:00 a.m. on November 23, 2009..."

November 23, 2009, at 1:00 p.m. - "...Dilantin level in A.M. (morning)...increase IVF (intravenous fluids) to 150 ml hr for 4 hrs then back to 125 ml hr...make patient full admit..."

November 23, 2009, at 4:29 p.m. - "...Ativan (minor tranquilizer) 2 mg IM x1 NOW..."

November 23, 2009, at 4:54 p.m. - "...Zofran (antinemetic) 4 mg IV (intravenous) q 6 hrs PRN (as needed)..."

November 23, 2009, at 11:50 p.m. - "...Dilantin level now...Ativan 2 mg IV PRN seizure activity..."

November 24, 2009, at 1:40 p.m. - "...Dilantin level Now..."

November 25, 2009, at 12:55 a.m. - "...Clarification: Cenestin (estrogen) 1.25 po (by mouth) daily...Paxil (antidepressant) 20 mg po daily...Tapazol (thyroid medication) 5 mg daily...Zofran 4 mg IV q 6 hr PRN..."

November 25, 2009, at 10:17 a.m. - "...Pt may take own Cenestin..."

November 26, 2009, at 1:30 p.m. - "...Dilantin level NOW..."

November 27, 2009, at 3:15 p.m. - "...Dilantin level in AM..."

November 28, 2009, at 11:30 a.m. - "...Dilantin level at 4:30 p.m..."

Review of the Medical Staff Rules and Regulations revealed "...Each verbal order...The responsible practitioner shall authenticate such order...Within 48 hours of when order was given..."

Interview in the cafeteria with the Chief Nursing Officer on March 2, 2010, at 3:00 p.m., confirmed the verbal orders were not dated or timed when signed by the physician. Continued interview confirmed the verbal orders are to be dated and timed when signed when authenticated by the physician.

Based on observation, facility document review, and interview, the facility failed to maintain dietary equipment, table top mixer and can opener, in a sanitary manner; failed to maintain the walk-in freezer in an ice free condition; and failed to remove dented cans from the ready-to-use storage units.


The findings included:

Observation on March 1, 2010, beginning at 10:40 a.m., with the Dietary Director present, revealed a small table top mixer with multiple dried white and brown splatters on the underside of the mixer (beater) arm. Further observation revealed a manual can opener slot with an accumulation of dried, sticky debris. Observation revealed the walk-in freezer floor, condenser unit and door frame had an accumulation of ice. Further observation revealed two, number ten cans, of chili; two, number ten cans, of refried beans, and thirteen, sixteen ounce cans, of cranberry sauce, dented on the side and/or rim, stored on the ready-to-use storage shelves or racks.

Review of facility document, entitled Nutritional Services Infection Control, page two, revealed "All equipment shall be thoroughly cleaned after each use". Review of the same facility document, page five, revealed "...mixer...and other appliances shall be disassembled, cleaned, sanitized, dried and reassembled after each use".
Review of the facility document entitled, Nutritional Services Cleaning Procedures, page one, revealed "Mixer 1. Take apart and clean all parts, using caution to clean underneath the mixer and under the beater area".
Review of the facility document, entitled Nutritional Services Food Storage Policy, revealed "All unlabeled, leaking, rusty, broken containers or cans with sides or rim dented or swells will be removed, marked unacceptable, and destroyed".

Interview, with the Dietary Director, present during the observations on March 1, 2010, beginning at 10:40 a.m., confirmed the mixer was "very dirty" and the mixer (beater) arm had "dried white and brown splatters". Further interview revealed the mixer was last used over the weekend to make white cake and chocolate frosting. Interview confirmed the can opener slot had dried, sticky debris present. Continued interview confirmed the walk-in freezer had a build-up of ice on the floor, condenser unit and door jam. Interview confirmed the ready-to-use store room shelves and/or racks contained two each, number ten cans of chili and refried beans, and thirteen, sixteen ounce cans of cranberry sauce, that were dented on the sides or rims. Further interview revealed the dented cans were to have been removed from the shelves and stored in the designated area for proper disposition..

Based on medical record review, facility policy review, and interview, the facility failed to assure discharge planning to include referral to an appropriate agency for one patient (#8) of thirty-five patient records reviewed.

The findings included;

Patient #8 was admitted to the facility on September 26, 2009, with diagnoses to include Contractions of Early Onset Delivery and Opioid (narcotic) Dependency. Continued medical record review revealed the patient had a Caesarean Section to deliver twins at 29 week gestation. Continued medical record review revealed the twins were transported immediately following delivery to (named) hospital for further care. Continued medical record review revealed the patient was discharged to home from the facility. Continued medical record review revealed no documentation or indication of a discussion related to consideration of a referral of the patient to an appropriate agency after discharge related to the patient's Opioid Dependency.

Review of the facility policy Neonatal Assessments for High-Risk Psychosocial Issues revealed "...Social Services will provide assistance and consultation as needed in the following types of cases:...Mothers with a history of drug abuse..."

Interview in the conference room with the Case Manager (acting in the Social Services role for the facility) on March 2, 2010, at 4:00 p.m., confirmed there was no documentation or indication of a discussion related to the patient's history of drug abuse as it impacts the patient and the newborns. Continued interview confirmed there was no documentation or indication of a discussion related to consideration of a referral of the patient to an appropriate agency after discharge related to the patient's Opioid Dependency.

Based on medical record review, document review, and interview, the facility failed to fully assess a patient transfer related to hospital care, services, and operations for one (#33) of thirty-five patients reviewed.

The findings included:

Patient #33 was admitted to the facility on August 9, 2009, with diagnoses including Acute Shortness of Breath, Clinical Pneumonia, Amyotrophic Lateral Sclerosis, Non-insulin Dependent Diabetes Mellitus, Hyponatremia, Fever and Chills.

Review of notes from the Nurse Practitioner dated August 11, 2009, revealed "Patient was placed on CPAP (Continuous Positive Airway Pressure) to help with getting rid of PCO2 (carbon dioxide)". Further review of Nurse Practitioner notes dated August 11, 2009, revealed "Attempt to remove CPAP at 4:00 a.m. with oxygen at four liters via nasal cannula. Patient lasted for approximately one minute. Oxygen saturation started dropping and CPAP was placed back on again." Review of a later note dated August 11, 2009, from the Nurse Practitioner, revealed ".... still very concerned that this patient may actually have an acute pulmonary emboli (blood clot in the lung) causing ... sudden shortness of breath. We have attempted to try and do a CT (computerized tomography) of ... chest, pulmonary embolus protocol, however, they do not have the ability to hook up the CPAP in x-ray and the patient is having a very difficult time being able to lay back. So we will be transferring .... emergency traffic as a direct admit to .......(hospital)."

Interview with the Director of Respiratory Therapy (RT) on March 3, 2010, at 8:30 a.m., in the conference room, revealed at the time the patient was in the facility there were two ventilators available for patients. The Director stated that x-ray does have the ability to hook up CPAP machines in the CT room but the patient would have had to be bagged ( squeezing bag to administer oxygen via mask) to and from the department. The Director was unable to state whether the other ventilator was in use at this time. The Director of RT spoke with the Director of CT scan who stated the CT was not performed because the patient refused to lie down and was sitting up on the table with CPAP on. The Director of RT stated there is a fully equipped intensive care unit in the hospital but it has not been open in a long time and any patients requiring a ventilator are transferred to another facility.

Interview with the Director of Quality Assurance (QA) on March 3, 2010, at 1:30 p.m., in the conference room, revealed "I look at transfers to some extent. I check that the transfer paper work is in order and the receiving facility is documented and that type of thing." The QA Director stated transfer records were reviewed based on patient request as well as anything brought by Case Management. The QA Director felt it was provider preference to transfer this patient to another facility. The QA Director stated "We do not have the staff to open the unit (intensive care unit); we need competent staff to open the unit. I didn't review this case because the patient went where ... needed to go and to the best Pulmonologist in ..... Why that particular provider wanted that transfer I don't know. If I review a chart and determine care was appropriate then it ends there." The QA Director stated .... had not spoken to the attending physician regarding the transfer; if the care was appropriate; and if there was anything different that could have been done.

Review of facility policy entitled "Emergency Medical Treatment and Transfer to Another Facility", the section on Quality Review stated "All transfers are measured, assessed, and reported on an on-going basis to the appropriate committees charged with monitoring the quality of care in the hospital."

Based on observation and interview, the facility failed to assure medications were disposed of properly in one of one procedure rooms located in the operating room (OR) core.

The findings included:

Observation of the sharps container (receptacle for disposal of needles) in the procedure room located in the OR core with the OR director and the QA (Quality Assurance) Director on March 1, 2010, at 2:20 p.m., revealed an approximate ? full, 13 gallon sharps container, with an opening on the top approximately 8 inches by 12 inches. Continued observation revealed the sharps container had syringes with needles attached and empty Propofol (anesthesia) vials. Continued observation revealed approximately 12 readily visible syringes which contained 5 - 20 ml (milliliters) of a white substance.
Interview in the procedure room with the OR Director on March 1, 2010, at 2:20 p.m., confirmed the substance in the syringes "...looks like Propofol...is to be wasted if not used...not left in the syringe..." Continued interview with the Director of the OR confirmed the medications were not disposed of according to protocol.