HospitalInspections.org

Based on interview and record review, the facility failed to take action aimed at performance improvement. The facility failed to retrain staff as proposed in the performance improvement plan to correct system problems identified during internal investigation of the allegations relating to complaint TX 00176227.
Finding:
Review of Patient ID# 9 medical record with Staff ID# 3, Nurse Manager revealed a 71 year old male admitted 12/21/13 for long term acute care of chronic obstructive pulmonary disease (COPD) and methicilin-resistant staphylococcus aureus (MRSA) pneumonia. Patient had poor appetite on admission and frequently refused meals and fluids. Patient was started on intravenous (IV) fluids, nutrition and antibiotics.

On 12/24/12 at 9:55am, a Peripherally Inserted Central Catheter (PICC) line placement was ordered. The facility ' s procedure nurse is primarily responsible for inserting the PICC line, and if unable or unavailable, a contracted provider is called by the nursing supervisor. The procedure nurse came in at 11:23pm but inserted a peripheral line instead of the PICC line ordered. Interview with staff on 5/14/13 in the conference room, she stated that she did not place the PICC line because she it was late and she was sick. She did not notify the doctor and was unsure if she informed the supervisor. Staff was out sick for the rest of the week.
The peripheral line inserted by the procedure nurse on 12/24/12 was removed by the patient two hours later. Patient was without IV access and did not receive his IV fluids, nutrition and medications until PICC line was inserted on 12/28/12 at 4:47pm. There was no evidence by the facility that the contracted vendor was contacted for PICC line placement.

On 1/3/13, patient was transferred to the Intensive Care Unit (ICU) for insulin drip to optimize control of his blood glucose levels, which increased when patient was placed on Total Parenteral Nutrition (TPN). Patient went into respiratory distress with tachypnea and hypoxia. Pulmonary and critical care was given; patient expired on 1/4/13.

Interview with Staff ID#7, night nursing supervisor for 12/24/12, she stated that she was not informed that patient had an order for PICC line and also was not notified by the procedure nurse that she was unable to insert the line. Staff added that the protocol requires that the nurse supervisor call the contracted provider when the procedure nurse cannot insert the central line and would have contacted the provider if informed.

Interview with Staff ID# on 5/14/13 during review of medical records she stated that patient daughter called expressing concern that her father was not eating and drinking. She informed patient ' s daughter that patient was refusing his food and pulling his IV line out. When asked why a request was not placed to the contractor for the procedure, staff stated " But he was refusing everything " . Staff added that the patient did not want the treatment but the family was insisting on the treatment. There was no documentation in the patient ' s medical record that patient refused the PICC line placement.

Interview with Chief Clinical Officer (CCO) on 5/14/13 in the conference room, she stated that she was not aware that the patient had a PICC line order until patient ' s wife reported to her on 12/28/13 that the patient had not received his IV fluids and medications since 12/25/13 because his PICC line had not been inserted. Staff explained that she immediately called the contracted provider, but when the company could not get it done same day, she called the facility ' s other campuses and was able to get a procedure nurse to insert the line same day. She added that she was on campus the week of 12/24/12 except on Christmas day and would have taken care of the problem if she was informed.

Review of the Summary Report of facility ' s Performance Improvement Team investigation revealed that internal investigation identified contributing factors as delay in PICC line placement and poor communication between staff. Actions taken include training and certifying four additional RNs for PICC line placement, a column added to the procedure log that indicates the date and time of the order as well as a completion date and time for tracking purposes, and monthly report to Patient Safety/Clinical Services Committee of number of PICCs ordered and placed within 48 hours. Other action proposed on the incident/grievance log was retraining of staff by 3/25/13.

Review of current patients with PICC lines and procedure log revealed that all PICC line orders are completed within 48 hours. Interview with CCO, Director of Quality Management (DQM) and Nurse Manager revealed that staff retraining was not completion as proposed. DQM added that she had a one to one counseling with the ICU nurse for failing to notify patient ' s family when he was transferred to ICU but acknowledged that actions aimed at performance improvement should be implemented throughout the hospital.

Review of facility ' s policy titled " Patient Complaint/Grievance Process " dated 02/2013 read under department head / management obligations: Participate with the leadership team to determine appropriate actions to resolve the issue including process improvement, increased monitoring, and appropriate employee action including additional training and coaching. "

Based on observation, interview and record review, the facility failed to ensure that established policies and procedures are maintained that address safety practices for food handling regarding food storage. This failed practice had the potential to harm the patients in the facility.

Findings:
During the tour of the kitchen with the Director of Food Services, the following items were not labeled or dated in the refrigeration section of the walk-in freezer.

1 Ziploc bag of boiled eggs
1 plate of sandwich
1 plate of salad
1 bowl of Pimento cheese
1 bowl of tuna salad
1 bowl of chicken salad, partly used
1 bowl of cottage cheese, partly used
1 bowl of sliced turkey, partly used
1 small container of jalapeno pepper
2 Ziploc bags of shredded cheese
1 bag of sliced cheese
1 tray of puree bread with a small portion leftover, dated 4/28/13.

Interview with Staff ID# 5, she acknowledged that it was her responsibility to ensure that food items in the refrigerator are labeled and dated. She stated that the puree bread was good for a week and should have been discarded. She added that food items are required to be dated before they are placed in the refrigerator.

Review of facility ' s policy and procedure titled " Food Storage " dated 06/2011 section (2) (g) read " All foods will be properly wrapped, dated and labeled and/or stored in sealed containers. This also applies to foods removed from original packing. Food will be discarded within appropriate storage life/expiration date. " And (4) (b) read " Leftovers will be used within safe time periods. All refrigerated leftovers will be used or discarded within 72 hours/3 days. "