HospitalInspections.org

Based on a Life Safety Code Validation survey, completed November 30, 2010, the Condition of Physical Environment is not met. Those deficient practices and the associated regulations can be found in the respective Life Safety Code survey (CKC921).

Based on observations, medical record review, and staff interview the facility failed time, date and complete orders for restraints for one of six current patients. (Patient #3)

The findings include:

An observation was conducted on 11/16/2010 at 2:09 p.m. which revealed Patient #3 in bed with multiple lines for medical support. Patient #3 had bilateral soft wrist restraints in place, which were attached to the bed frame.

A review of Patient #3's medical record was conducted on 11/16/2010 in the presence of Staff #12, the Nurse Manager for the Intensive Care Unit (ICU) and Staff #14, the Director of Nursing Operations. Patient #3 a 41 year old was admitted to the hospital on 11/13/2010 through the Emergency Department with diagnoses that included septic shock and acute respiratory failure.

Patient #3's medical record included forms titled "Restraint Orders for Support of Medical Healing". The "Restraint Orders for Support of Medical Healing" dated 11/14/2010 indicated the order had been a telephone order taken on 11/14/2010 at "1000" (10:00 a.m.). The "Restraint Orders for Support of Medical Healing" space for physician signature, date and time was blank. The time to indicate the implementation or noting of the "Restraint Orders for Support of Medical Healing" was blank. A review of the physician progress notes for 11/14/2010 did not reveal a physician documented the assessment of Patient #3 for the restraint order. A "Restraint Orders for Support of Medical Healing" form signed by a physician on 11/16/2010 at "12 noon" did not have a documented date and time for implementation or noting. The 11/16/2010 "Restraint Orders for Support of Medical Healing" did not document the clinical justification for the use of restraints, the type of restraint to be utilized or which of Patient #3's extremity should be restrained.

The "Restraint Orders for Support of Medical Healing" forms, dated 11/14/ 2010, 11/15/2010, and 11/16/2010, the section for notification of family had been left blank.

An interview was conducted on 11/16/2010 at 2:20 p.m. with Staff #12 and Staff #14. Patient #3's "Restraint Orders for Support of Medical Healing" orders were presented to Staff #12 and Staff#14; Staff #12 stated "The restraint order for the fourteenth should have been signed by the physician and completed either by the nurse or the physician. The order for the sixteenth is just not complete." Staff #12 reported the section for notification of the family on the "Restraint Orders for Support of Medical Healing" was always left blank on subsequent orders after the initial notification of the family. When asked if the subsequent orders were a continuation of the initial order; Staff #12 stated "No, each order for restraints are a new order." When asked if a patient had subsequent orders for restraints with each order being separate occurrence wouldn't the family need to be notified that the patient had been assessed and a less restrictive intervention had failed; Staff #12 reported since the family had been notified on the initial order staff did not notify them of the ensuing assessment and continued need for restraints. A request was made for the hospital's policy for restraint use. Staff #14 reported the policy had been scheduled for revision; the surveyor requested the policy in use during the timeframe of 11/13/2010 through 11/16/2010.

Review of the hospital's policy titled "Restraints" related to the completeness of the orders read: "C. Orders: 3. Documentation of Orders - All orders must be in writing. The order will be documented on the Restraint Order Form and at a minimum must include: a. The reason for restraint use (clinical justification/rationale); b. The type of restraint; and c. The time limits of the order."

Review of the hospital's policy titled "Restraints" related to the renewal of restraint orders and status of each order as a new order read: "C. Orders: 8. Renewal of Orders a. Continued Clinical Justification- If restraint use continues to be clinically justified beyond the time limits noted in the original order, a new time limited order must be obtained."

Review of the hospital's policy titled "Restraints" related to the notification of family read: "F. Notification and Education of Patient/Families 1. Nonviolent Restraints: a. Family or as applicable guardian or designated health care agent, will be informed of the application of the the restraint within a reasonable time frame (should not exceed 12 hours). b. The notification should be documented on the Support of Non Violent Restraint Assessment." Review of the hospital's policy did not reveal that the family would not be notified if the patient was re-assessed and a restraint was applied.

Based on observations, staff interviews and review of facility policies the facility staff failed to ensure that expired medications and opened and accessed medications with no date as to when opened were not available for use.

The Findings Include:

During tour of the Anesthesia work room with the Director of Surgical Service on 11/16/10 at approximately 10:05 A.M. the pharmacy cart was inspected and contained four 10 ml (milliliters) boxes Sodium BiCarb labeled with the expiration date of 1NOV10 (November 1, 2010).

The Pharmacy Buyer and Director of Pharmacy arrived during the inspection. The Pharmacy Buyer stated, "This cart is refilled each day by the pharmacy. The pharmacy is responsible for checking for expiration dates. Those medications should have been removed."

During the inspection a surgical tech came into the room opened one of the drawers on the pharmacy cart and removed a handful of vials. The pharmacy tech was not observed checking expiration dates.

Also during the tour of Surgical Services with the Director of Surgical Services the operating room designated as the Eye Room anesthesia cart was inspected and was noted to have one 5 ml vial of Rocuronium Bromide with the expiration date of 11/15/10, one 10 ml vial of Furosemide with the expiration date of Aug10 (August 2010) and one 40 ml multi use vial of Labetalol Hydrochloride which had been opened and accessed with no date indicating when it would expire since being opened and accessed.

The VP of Quality provided a policy titled Multi-Dose Vials. The policy indicates once opened all multi-dose vials are to be discarded 28 days after opening or at the manufactures' expiration date, whichever is shorter....

Based on observations and staff interviews the facility staff failed to ensure the maintenance of a sanitary hospital environment:
1. The Emergency Department (ED) floor had large amounts of dust and dirt, the gurneys had tape residue, the Electrocardiography Machine (EKG) had dried gel and hair in numerous places and the ice machine did not have an air gap.
In the Surgical Suite 2 Ether Screens were found lying on the floor with a gauze wrap around both and a Wilson frame was on a gurney with stocking net over egg crate padding. Also the gurney in the surgical suite had tape residue and one gurney was found with torn covering on the head rest.
In the Physical Therapy Department patient equipment was found stored in the restroom used by staff members.
2. Seven of 8 patient units toured were found to have ice machines without air gaps.
3. Failed to maintain the kitchen in a clean and sanitary manner.
The Findings Include:
1. During the initial tour of the Emergency Department on 11/16/10, at approximately 9:10 A.M. with the Emergency Department Manager (EDM) and the Vice President of Emergency Department Services (VPEDS), the floor was noted to have large amounts of dust and debris around the equipment and counters of the ED. The EKG machine was found to have dried gel and hair in numerous places on the machine including the wires which lay on patients' chest during the procedure of an EKG.
The gurneys (on which patients were observed laying on) had tape residue on the sides making disinfecting the gurneys between patient use almost impossible
The ice machine in the ED was found to not have an air gap which prevents the back flow of a solid, liquid, or gas contaminant into the water supply system.

Maintenance Personnel (Employee #6) stated, "What do you mean by an air gap?"
The VPEDS stated, "We will have all this corrected by tomorrow." "We do not have a specific dedicated environmentalist (housekeeper) to the ED."
During the tour of the Surgical Suite with the Director of Surgical Services (DSS) on 11/16/10 at approximately 10:05 A. M. in the surgical "Eye Room" 2, Ether Screens were found on the floor leaning against the wall. The screens were squared U shaped metal with padding and gauze wrapped around the center of the U. The DSS stated "They (the Ether Screens) are hooked to the table across the patients head and the sterile surgical drapes are put over the screens." "They are used to hold the drape off the patient's face during surgery." The DSS stated, "They should not be on the floor." The DSS could not explain how the Ether Screens are cleaned between uses.
Also during the tour of the Surgical Suite a Wilson Frame was observed lying on a gurney. The Wilson frame had two slightly curve wide bars with egg crate padding and stockingnet on each bar. The DSS explained, "They are used to hold the patient's torso up when the patient is lying on their abdomen so the patient can breath." The DSS stated the padding and stockingnet is removed between each patient. The padding and stockingnet observed on one off the Wilson frames appeared faded, soiled with Betadine and used. The other Wilson frame appeared cleaner and not faded. The DSS stated, "We need to come up with a way to be able to clean these between patients."
The several of the gurney's in the Surgical Suite were found to have tape residue on the sides and padding. One of the gurney's head rest was found to have small tears. The DSS stated, "They need to be cleaned and replaced."
The Physical Therapy Department (PT) was inspected on 11/17/10. The PT was a converted patient room with a bathroom. The bathroom contained approximately 17 crutches, 5-6 walkers, 3-4 arm supports, 3-4 reachers wrapped in bags and a few various other pieces of equipment. A Physical Therapist (employee #23) was asked how long the PT had been in the converted patient room. She stated, "It has always been this way since I have been here (about 4 years)." "Not to many offices have a private bathroom."
The Director of Physical Therapy was present and was asked if the bathroom was used for toileting and by whom. She stated, "The PT staff use it (the bathroom)." She stated, "The equipment is cleaned between patient use and placed in the bathroom." The PT Director stated, "The equipment might be cleaned and it might not be cleaned when it is taken out of the bathroom for patient use."


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2. Observations and interviews were conducted on 11/16/2010 from 11:52 a.m. through 12:30 p.m. with Staff #14, the Director of Nursing Operations and Staff #22 the hospital's Engineer; related to the seven ice machines located on the nursing units. The observations revealed:
· At 11:52 a.m. in the presence of Staff #14 and Staff # 21 the Nurse Manager the General Surgical unit's ice machine drain line was directly coupled into the sink drain plumbing approximately three inches above the U-joint. The line did not have a mechanism to stop the backflow of contaminated drain water from the sink's sewage system into the ice machine. The ice machine drain line did not have an air gap to prevent the migration of microbes/bacteria from the sink drain into the ice machine. The observation revealed a 18 inch long x (by) 9 inch wide x 3 inch deep metal pan under the sink U-joint that had overflowed with a black brackish water with an acidic smell. Interviews were conducted with Staff #21. Staff #21 stated "I didn't know that was under there, no one told me the sink was leaking." Staff #22 stated "The ice machine drain is tied directly into the sink drain, there's no air gap, or trap to prevent backflow."

· At 12:08 p.m. in the presence of Staff #14 and Staff #22; the Medical/ Surgical unit's ice machine drain line rested directly on the top of the sink's edge. The open end of the ice machine's drain line was in direct contact with standing liquids. That area of the sink's top was wet and had a white scaly material surround the open end of the drain. Staff #22 stated "There is not an air gap present on this one either." Staff #22 verbally verified the open end of the ice machine's drain line was in direct contact with both the scaly white material and standing liquid.

· At 12:17 p.m. in the presence of Staff #14 and Staff #22; the General Intensive Care Unit's ice machine drain line rested inside the hand washing sink in direct contact with the sink's inner surface. Staff #22 reported the drain was in direct contact with the sink surface and needed to be adjusted to prevent the migration of microbes/bacteria from the sink's surface into the ice machine.

· At 12:20 p.m. in the presence of Staff #14 and Staff #22; the second Intensive Care Unit's ice machine drain line was directly coupled into the sink drain plumbing. The observation did not reveal a mechanism to stop the backflow of contaminated drain water or prevent the migration of microbes/bacteria into the ice machine. Staff #22 stated "This one is set up just like the other unit. We'll need to put a trap in place."

· At 12:23 p.m. in the presence of Staff #14 and Staff #22; the Oncology unit's ice machine drain line was directly coupled into the sink drain plumbing. The observation did not reveal a mechanism to stop the backflow of contaminated drain water or prevent the migration of microbes/bacteria into the ice machine. Staff #22 stated "This one is set up just like the other two units."

· At 12:26 p.m. in the presence of Staff #14 and Staff #22; the Cardiovascular unit's ice machine drain line extended through an opening in the floor drain. The ice machine's drain extended below the level of the floor and was covered with a black film and black jellied substance. Staff #22 stated "I don't know how that (the black jellied substance) got there." After Staff #22 observed the drain line, which extended below the level of the floor, he reported the drain needed an air gap above the drain in the floor.

· At 12:30 p.m. in the presence of Staff #14 and Staff #22; the Birthing Center's ice machine drain line was directly coupled into the hospital's drain plumbing. The observation did not reveal a mechanism to stop the backflow of contaminated drain water or prevent the migration of microbes/bacteria into the ice machine. Staff #22 reported the system needed to be changed to install an air gap or trap.


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3. Two surveyors toured the kitchen area on 11/16/10 at 11:15 a.m. The dietary manager, executive chef, and a member of the facility management team accompanied the surveyors on the tour. The registered dietician manager joined part way through the tour.

The kitchen area included several stainless steel refrigerators and warmers. Some were walk-ins and others were reach-ins. The doors appeared to have smudges/hand marks, especially around the door handles. There were layers of grime on some of the handles. The executive chef was able to remove some of the grime with her fingernail.

The surveyors also observed grime around the perimeter of the floor and on the baseboards. The dietary manager and executive chef informed the surveyors that the staff had assignments and a schedule for cleaning the equipment in the directory department. The department did not maintain documents of when cleaning was performed.

On 11/17/10 at 2:20 p.m., the dietary manager provided copies of policies and procedures for cleaning various items in the kitchen. A policy titled, 'DRINKING FOUNTAINS, ICE MACHINES, REFRIGERATORS, CLEAN' addressed the cleaning of the refrigerators. "Use a clean, lint-free cloth dampened in the disinfectant cleaning solution. Wring out all excess solution to avoid drips. Damp wipe all exterior surfaces of the refrigerator. Particular attention should be paid to handles where fingerprints and smudges occur."

The dietary manager stated that the refrigerators and floors had been cleaned on 11/16/10 and the morning of 11/17/10, and the area looked "better".