HospitalInspections.org

Based on interview and record review, the hospital failed to have a current Hospital License from the Department of Health and Hospitals.
Findings:
Review of the State Hospital license presented by the hospital as the most current revealed an expiration date of 8/31/13.
In an interview on 10/23/13 at 12:54 p.m. with S2QualityDir, she said the hospital did not have a current hospital license from the Department of Health and Hospitals because there was an error in the paperwork involving the correct name of the hospital after the recent change of ownership.

Based on interviews and record reviews the facility failed to ensure that the Medical Staff enforced the by-laws and the rules and regulations adopted by the Medical Staff. This failed practice was evidenced by the Medical Staff failing to enforce their medical record Delinquency Policy for 1 (S35MD) physician with medical record delinquencies more than 120 days.

Findings:
A review of the facility policy titled: "Delinquent Incomplete Medical Records", provided by S15MR Director as the most current, indicated that physicians shall receive written delinquency notices from the HIM (Health Information Management) department regarding the status of their delinquent medical records. The policy indicated that the HIM department will notify the MEC (Medical Executive Committee) of physicians with delinquent records over 60 days and a certified letter will be sent to the physician. In the event that the physician's medical records are delinquent at 90 days, a second certified letter will be sent to the physician. If the delinquent medical records are not completed within 7 days after the second 90 day letter was sent, the physician will be notified that their hospital privileges are being terminated.

A review of the facility's Deficiency Chart for the month of October 2013 reveled that S35MD had 2 delinquent records over 90 days and 1 delinquent record over 120 days.

A review of the facility's Admissions By Physician printout revealed S35MD had admitted 4 patients in the month of October 2013 and 16 patients in the month of September 2013.

In an interview on 10/22/13 at 11:00 a.m. with S15MR Director she indicated that the hospital had no physicians on suspension. S15MR Director was asked about S35MD's 120 day delinquent medical record. S15MR Director indicated that the MEC had approved that a letter (first letter) be sent to S35MD on 08/20/13 indicating that she had 5 delinquent medical records over 60 days. S15MR Director further indicated that the MEC had not approved a second letter to be sent to S35MD when she had delinquent medical records over 90 days. S15MR Director indicated that S35MD also had 1 delinquent medical record over 120 days. S15MR Director indicated that S35MD still had delinquent medical records and further indicated that S35MD's (2) 90 day delinquent medical records will probably be 120 days delinquent and S35MD (1) 120 day delinquent medical record will probably be 150 days delinquent by the next MEC meeting in November 2013. S15MR Director indicated that physicians received emails and text messages through the HPF (Horizon Patient Folder) system when they have delinquent medical records.

In an interview on 10/22/13 at 1:30 p.m. with S2QualityDir, in the presence of S15MR Director, she indicated that a second letter to S35MD should have been sent to S35MD by the MEC when she had delinquent medical records over 90 days.

Based on record reviews and interviews the hospital failed to ensure the registered nurse (RN) supervised and evaluated the care of each patient by failing to ensure physicians orders were implemented for 3 of 24 current patients in a total of 41 sampled patients (#17, #28, and #38).
Findings:

1. Patient #17:

Review of the medical record revealed the patient was an eighty-five year old gentleman admitted to the hospital on 10/21/13. The patient had the diagnoses of Congestive Heart Failure and Coronary Artery Disease.

Review of a Cardiac Caths Report revealed the patient had a left and right heart catheterization procedure done on 10/21/13. Review of this report revealed the patient's case ended at 4:56 p.m. Review of the Vital Signs section of this report revealed the last documented vital signs were at 5:11 p.m.

Review of the physician's Post-Cardiac Catheterization Orders dated 10/21/13 revealed, in part: Check B/P (blood pressure) & HR (heart rate) every 15 minutes x 2, then every 30 minutes x 2, then every 1 hour x 2 and as needed.

Review of the medical record revealed the patient was admitted to a medical-surgical room on 10/21/13 at 6:15 p.m.

Review of the medical record revealed the patient's vital signs were recorded on 10/21/13 at 6:20 p.m., 7:47 p.m., and 9:00 p.m.

In interview on 10/22/13 at 1:16 p.m., S4/RN indicated there was no documented evidence the physician's post-cardiac catheterization order to check blood pressure and heart rate were implemented as ordered.


2. Patient #28:

Review of the medical record revealed the patient was a sixty-six year old female admitted to the hospital on 10/22/13 for a total knee replacement.

Review of the Post-Op Knee Inpatient Orders revealed, in part: Upon Arrival to Floor: BP/HR/RR(respiratory rate)/Pulse Ox/Neurovascular Check every 15 minutes x 2, then every 30 minutes x 2, then every 1 hour x 2, then every 4 hours, then routine.

Review of the medical record revealed the patient was discharged from PACU (post-anesthesia care unit) on 10/22/13 at 12:57 p.m.

Review of the medical record revealed the patient was admitted to a medical-surgical room on 10/22/13 at 1:05 p.m.

Review of the medical record revealed the patient's vital signs and neurovascular checks were recorded on 10/22/13 at 1:05 p.m., 4:19 p.m., 7:35 p.m., and 11:15 p.m.

In interview on 10/23/13 at 9:46 a.m., S4/RN indicated there was no documented evidence the physician's post-op knee inpatient orders for BP/HR/RR/Pulse Ox/Neurovascular Check orders were implemented as ordered.


3. Patient #38
Findings:
Patient #38 is a 65-year-old female admitted to the hospital on 10/17/2013 with the diagnoses of depression, mania, GERD (Gastroesophageal Reflux Disease) and Hypertension (HTN).
Review of the history and physical, psychiatric evaluation, and initial Registered Nurse assessment, revealed Patient #38 had a diagnosis of Hypertension. Review of Patient #38's medication list revealed she had an order for anti-hypertensive medication.
Review of the physician admit orders dated 10/17/13 revealed an order for "Routine" vital signs. Review of the policy, "PC-105: Scope of Services-Nursing," effective 08/01/13, revealed in part: "Patient Vital Signs will be obtained and monitored BID (twice daily), on a daily basis, unless otherwise specified by MD or NP (nurse practitioner)."
Review of Patient #38's medical record revealed vital signs were recorded as follows: 10/17/13 at 7:52 p.m.; 10/17/13 at 9:24 p.m.; 10/18/13 at 10:38 a.m.; 10/19/13 at 8:00 a.m.; 10/20/13 at 8:00 a.m.; 10/21/13 at 8:00 a.m.; and 10/21/13 at 5:37 p.m.
In a face-to-face interview on 10/22/13 at 4:45 p.m., S22DirPsych verified that the above referenced policy was the current policy in effect, and the above referenced documented vital signs were the only vital signs recorded for Patient #38 in the medical record. S22DirPsych further verified the physician's order for routine vital signs had not been implemented.





31048

Based on interviews and record reviews, the hospital failed to develop comprehensive nursing care plans for 2 (#25, #38) of 2 current psychiatric patients reviewed as evidenced by failing to identify problems and develop interventions for identified problems.

Findings:

Review of the hospital policy presented as current titled Documentation of Patient Care: Patient's Plan of Care, Reviewed/Revised 10/13, revealed in part:
7. On an ongoing basis, all changes made to the care plan (i.e. completion/addition of problems, revisions to text, goals, or interventions) are compiled in the Plan of Care. In this manner, all caregivers contribute directly to the ongoing evolution of the patient's Plan of Care. The nurse will then be responsible for reviewing and prioritizing all problems identified for the patient. Using the process intervention screen, evolution of the Plan of Care will be a continuous, interdisciplinary responsibility.

Patient #25
Review of the medical record for Patient #25 revealed he was a 52 year old current resident admitted on 10/14/13 with diagnosis which included Chronic Paranoid Schizophrenia, Suicide Attempt, Depression, Ineffective Coping, Hypertension, Diabetes, GERD (Gastroesophageal Reflux Disease), and Obstructive Sleep Apnea.

Review of the care plans for Patient #25 revealed he had no interventions listed for the identified problems of Depression, Chronic Pain, Chemical Dependency, Altered Endocrine Function, Altered Integumentary Function, Actual/Potential Elopement, Risk for Restraints, Potential for Self-harm, or Altered Nutritional Status.

In an interview on 10/22/13 at 4:15 p.m. with S31RN, she said the nursing care plans for the patients were generated by the computer based on the admission assessment by the nurse. S31RN said she thought the computer automatically populated the care plans with diagnosis and interventions. S13RN said the nurses reviewed the care plans daily, but was not aware the care plans for the patients did not have interventions listed unless chosen by the nurse. S31RN verified Patient #25 did not have any interventions listed on his care plan.

In an interview on 10/22/13 at 4:20 p.m., S22DirPsych said she thought the computer populated the care plans automatically for the patients with the diagnosis and interventions. S22DirPsyc said she was not aware the nursing care plan for Patient #25 did not have interventions listed for recognized problems. S22DirPsyc said the care plans were not individualized for any of the patients.

Patient #38

Patient #38 is a 65-year-old female admitted to the hospital on 10/17/2013 with the diagnoses of Depression, Mania, GERD (Gastroesophageal Reflux Disease) and Hypertension (HTN).
Review of the history and physical, psychiatric evaluation, and initial Registered Nurse assessment, revealed Patient #38 had the above referenced diagnoses documented in the medical record. Review of Patient #38's medication list revealed she had an order for anti-hypertensive medication. Further review of the physician orders dated 10/22/13, at 1:50 p.m., revealed an order to increase Norvasc (antihypertensive) to 10 mg (milligrams) by mouth daily.
Review of Patient #38's nursing care plan revealed the diagnosis of hypertension was not identified on Patient #38's nursing care plan. Further review of the care plan revealed there were no interventions listed for any of the problems identified on the nursing care plan.
In a face-to-face interview on 10/22/13 at 4:45 p.m., S22DirPsych verified the above referenced care plan was the only nursing care plan utilized to implement nursing care for Patient #38. S22DirPsych further verified the nursing care plan did not have a diagnosis of hypertension identified on the nursing care plan, and the nursing care plan did not have any interventions listed for any of the problems identified on the care plan.






31048

Based on observation and interviews, the facility failed to have a system in place to ensure that medical records were stored and maintained in a location where the medical records were protected from damage to include damage from water and fire. This failed practice was evidenced by medical records being stored on open shelving racks in the Medical Records Department with multiple sprinkler heads on the ceiling and no means to protect the medical records on the shelving racks if the sprinkler system was activated or if there was a fire in the department.

Findings;
An observation on 10/22/13 of the Medical Records Department revealed medical records being stored on multiple open shelving racks throughout the Medical Records Department with no means to protect the medical records on the shelving racks if the sprinkler system was activated or if there was a fire in the department. A further observation revealed multiple sprinkler heads located on the ceiling throughout the Medical Records Department.

In an interview on 10/22/13 at 11:00 a.m. with S15MR Director she indicated that the medical records stored on the shelving racks in the Medical Records Department contained mostly the original medical documents and only the medicals record documents after 09/11/12 were completely scanned into the medical record computerized software. S15MR Director further indicated that the Medical Records Department did not have a system in place to protect the stored medical record documents prior to 09/11/12 from water damage or fire damage.

In an interview on 10/23/13 at 9:50 a.m. with S2Quality Dir she indicated that the hospital did not have any policies in place that addressed the protection of the medical records, presently stored on the open shelving racks in the Medical Record Department, from water damage or fire damage. S2Quality Dir further indicated that the Medical Records Department did not have a system in place to protect these medical record documents prior to 09/11/12 from water damage or fire damage.

Based on record reviews the facility failed to ensure that all clinical medical record entries were authenticated, dated and timed according to Medical Staff Rules and Regulations. This failed practice was evidenced by 3 patient medical records (#5, #6, #12 ) out of 41 sampled patient medical records.

Findings:
A review of the Medical Staff Rules and Regulations dated 2013, provided by S2QualityDir as the most current, revealed in part: All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated.

Patient #6
A review of Patient #6's medical record revealed the patient was scheduled for a surgical procedure on 10/21/13. A further review of Patient #6's "Patient Consent to Medical Treatment or Surgical Procedure..." revealed that the physician had signed and dated the consent form with no time noted as to the time when the physician had obtained the surgical consent from Patient #6.

Patient #5
Patient #5 was a 68 year-old male admitted to the hospital on 10/19/13 with the diagnoses of Acute Renal Failure.
Review of Patient #5's medical record revealed the following telephone/verbal orders were authenticated by S17MD, but were not dated or timed:
10/20/13 at 11:00 a.m., "Echocardiogram (R/O [rule out] heart failure); collect stool x 3 for occult blood; schedule sleep study at Sleep Solutions at time of discharge; in am CBC (complete blood count), CMP (comprehensive metabolic panel); Crestor 10 mg (milligrams) po (by mouth) daily"
10/20/13 at 4:35 a.m., "Ultram 50 mg po every 4 hours prn (as needed) pain"
10/20/13 at 9:40 a.m., "Troponin, cardiac enzymes now; decrease IVF (intravenous fluids) to 75 ml/hr (milliliters per hour); d/c (discontinue) heparin; apply bilateral SCDs (sequential compression device); hold Valsartan; no NSAIDS (medication) or Cox II inhibitors (medication); T & M (type and match) and hold 2 units PRBCs (packed red blood cells)"
10/20/13 at 12:55 p.m., on the Dauterive Medicare Order Form, "Admit to inpatient status"
Review of Patient #5's medical record revealed the following telephone/verbal order was authenticated by S18MD, but was not dated or timed:
10/20/2013 at 6:30 p.m., "Accurate I & 0s (intake and output); 24 hour urine for protein and creatinine; NS (normal saline) 200 ml with 25 grams albumin and 200 mg Lasix at 10 ml/hr; avoid NSAIDS, ACE-I, ARBS (medications); d/c Diovan; labs in am: CBS, CMP, Mg (magnesium), phosphorus (peditubes); Renvela 800 mg, one tab po TID (three times per day) with meals; renal diet; iron studies (use blood from today)"
In a face-to-face interview on 10/22/13 at 10:45 a.m., S23DirRespiratory confirmed the above referenced verbal/telephone orders did not have a date or time documented with the physician authentication.

Patient #12
Patient #12 was a 52 year-old female admitted on 10/10/13 at 6:50 p.m.with the diagnosis of COPD (Chronic Obstructive Pulmonary Disease).
Review of Patient #12's medical record revealed the following telephone/verbal orders were authenticated by S19MD, but were not dated or timed:
10/19/13 at 4:35 p.m., "1 on 1 supervision with family member or staff; Ativan 1 mg, IVP (intravenous push) prn anxiety every 6 hours"
10/19/13 at 7:50 p.m., "Nicotine patch 21 mcg (micrograms) one transdermal every day"
Review of Patient #12's medical record revealed the following orders were not authenticated:
10/10/13 at 10:00 p.m., "All ICU Patients (Admits & Readmits)" preprinted order sheet including orders for "Skin Cleaning - Bathing" and "Nasal Medication" signed off by S24RN with no identification/authentication of prescribing practitioner.
10/11/13 at 12:02 a.m., PICC Line Placement Orders" preprinted order sheet as a telephone order by S20MD
10/16/13 at 8:15 a.m., "Decrease Librium 10 mg po every 8 hours, ambulate in room; PT (Physical Therapy) evaluate and start ambulation" (unable to identify physician, no signature)
In a face-to-face interview on 10/22/13 at 11:45 a.m., S21RN confirmed that the above referenced physician orders were not authenticated.
10/17/13 at 10:20 a.m., "Acute Care Clarification Orders" or Physical Therapy services to be provided.
In a face-to-face interview on 10/22/13 at 2:06 p.m., S5ST confirmed that the above referenced order for physical therapy services had not been authenticated by the physician.



31048

Based on interview and record review, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with acceptable standards of practice for 8 (#16, #18, #19, #24, #33, #34, #35, #36) of 34 current patients at the hospital. This deficient practice is evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Findings:
Review of the hospital policy titled Medication Orders, revised 6/13 stated in part:
B. Pharmacy shall process drug orders as follows:
2. A pharmacist shall review the prescriber ' s original order, or a direct copy thereof, before the initial dose is dispensed (with the exception of emergency orders when time does not permit). This review shall include the patient ' s demographic information (age, weight, allergies, diagnosis), laboratory values, food drug interactions, therapeutic duplication and drug therapy (current drug regimen).
3. If an order is written when the pharmacy is closed, or the pharmacist is otherwise unavailable, it should be reviewed by the patient ' s nurse and nursing supervisor, and then by a pharmacist upon opening.

Review of a list provided by S33DirPharmacy of first dose non-emergent medications administered after pharmacy hours from 10/20/13 until 10/21/13 revealed 27 medications had been dispensed to 8 patients before being reviewed by a pharmacist for appropriateness. The following medications were dispensed:
Patient #16: Acetaminophen 500 mg (milligrams)
Patient #24: Hydromorphone 1 mg/ml (milliliter) - listed as high alert medication, Promethazine HCL (hydrochloride) 25mg/1ml vial
Patient #33: Menantine 5 mg tab (tablet), Amlodipine Besylate 5mg tab, Prevastatin Sodium 20mg tab.
Patient #36: Magnesium Oxide 400mg tab.
Patient #34: Lorazepam 2mg/1ml inj (injectable).
Patient #24: Hydroromorphone 1mg/ml inj - listed as high alert medication, Promethazine HCL 25mg/1ml
Patient #35: Amlodipine Besylate 2.5mg tab.
Patient #36: Furosemide 40mg/4ml vial, Hyralazine HCL 25mg tab, Isosorbide Mononitrate 30mg tab.
Patient #33: Paroxetine HCL 20mg tab, Levofloxacin/Dextrose 5% water 250mg/50mls, Enoxaparin Sodium 40mg/0.4ml, Pantoprazole 40mg tab
Patient #19: Albuterol/Ipratropium 3ml solution (twice)
Patient #18: Acetaminophen 325mg tab, Furosemide 20mg/2ml vial
Patient #19: Furosemide 20mg/2ml vial, Haloperidol 5mg/1ml vial
Patient #18: Tramadol HCL50mg tab, Norephinephrine Bitartrate 4mg/4ml vial, Methylprednisolone 125mg/2ml vial

In an interview on 10/21/13 at 2:30 p.m. with S33DirPharmacy, she said the hospital pharmacy hours were Monday through Friday from 6:30 a.m. until 8:30 p.m. and on weekends and holidays from 7:00 a.m. until 3:30 p.m. S33DirPharmacy said when a medication was ordered at night, the nursing supervisor could get the medication out of a locked cabinet. After the medication was removed from the cabinet, S33DirPharmacy said a one-time medication order was generated in the computer system. S33DirPharmacy said a pharmacist did not review the newly ordered medications for appropriateness before the patient received the first dose. S33DirPharmacy said the doses given at night were not reviewed until the pharmacist arrived in the morning. S33DirPharmacy verified this practice was a second dose review of the medications and if an error in the medication order had happened, the patient would have received the first dose before it had been reviewed by the pharmacist. S33DirPharmacy said the nursing supervisor reviewed the medication with the patient ' s nurse when it was removed from the medication cabinet at night. S33DirPharmacy verified the nursing supervisors at the hospital were not licensed pharmacists. When asked why a pharmacist had to review the first dose of a medication during pharmacy operating hours per policy, but a nurse could review the medications after hours, she said because there was no other way it could be done because a pharmacist was not at the hospital.

Based on interview and record review, the hospital failed to ensure medication errors were reported to the attending physician for 5 (#39, #40, #41, #42, #43) of the last 7 medication errors reported at the hospital.

Findings:

Review of the last 7 medication error incident reports presented by S2QualityDir revealed 5 of the documents were marked as " N " for " no " next to a space titled " Physician Notified " .

Review of a medication incident report for Patient #39 dated 10/18/13 revealed she had an adverse drug reaction. Next to a space on the incident report to indicate if the physician had been notified, an " N " for no was documented.

Review of a medication incident report for Patient #40 dated 10/18/13 revealed she had an O2 tank that was supposed to be on 2 liters at all times but was not turned on. A description of the event stated in part: Patient (Pt) was seen in OT gym with signs of fatigue. Pt stated " Something is not right, it is hard to talk " . Pt noted to have slow effortful speech. O2 tank was checked by SLP; tank was half way filled however not on. Next to a space on the incident report to indicate if the physician had been notified, an " N " for no was documented.

Review of a medication incident report for Patient #41 dated 10/15/13 revealed she had been given 4mg of Decadron intravenously instead of per inhalation. Next to a space on the incident report to indicate if the physician had been notified, an " N " for no was documented.

Review of a medication incident report for Patient #42 dated 10/19/13 revealed 2mg of Morphine had been given to her after it had been discontinued and the patient had been placed on a PCA pump. Next to a space on the incident report to indicate if the physician had been notified, an " N " for no was documented.
Review of a medication incident report for Patient #43 revealed the first dose of Zithromax had been omitted and delayed for 12 hours. Next to a space on the incident report to indicate if the physician had been notified, an " N " for no was documented.

In an interview on 10/21/13 at 3:30 p.m. with S2QualityDir, she verified 5 of the last 7 medication errors reported to the facility had not been documented as having been reported to the physician. S2QualityDir reviewed medical records for each of the 5 patients and could not locate any documentation that the physician had been notified of the medication errors. S2QualityDir stated the physician ' s should have been notified of the errors.

30364


Based on interviews, observations, and record reviews, the hospital failed to ensure the infection control officer implemented measures to prevent and control infections and communicable diseases as evidenced by:
1) failing to ensure the proper cleaning of the emergency department (ED) rooms between patients for 2 (#1, #5) of 10 rooms;
2) failing to ensure personal protective equipment was worn correctly by a member of the nursing staff in the ED for 1 (#2) of 1 (#2) patients in the ED on contact precautions;
3) failing to ensure a pharmacy technician wore a hair covering while stocking the medication dispensing system in the cesarean section operating room;
4) failing to ensure a laboratory technician washed her hands after removing dirty gloves and before leaving the ED;
5) failing to ensure an isolation room on the psychiatric unit was properly cleaned for patient use;
6) failing to ensure compliance with the hospital's Employee Health Program for TB screening for 1 physician (S32MD) out of 4 physician files reviewed and for 1 employee (S6Dir Surgical Services) out of 6 employee files reviewed.

Findings:

1) Failing to ensure the proper cleaning of the emergency department rooms between patients.
Room #1
An observation on 10/21/13 at 10:55 a.m. of ED room #1 revealed two red spots approximately 1 inch in diameter on the bed frame underneath the mattress.

In an interview on 10/21/13 at 1100 with S24DirCriticalCare, she said room #1 had been cleaned and was ready for a new patient. S24DirCriticalCare verified there were red spots underneath the mattress in room #1 and said the red spots were, " definitely dried blood. " S24DirCriticalCare said the bed in room #1 should have been completely cleaned after the previous patient was discharged.

Room #5
Observation of emergency department room #5 revealed a medicine vial cap and 4 pieces of paper on the floor. Further review revealed 4 alcohol prep pads located on the top of a glove box on the wall. Observation of the bed revealed the top of the mattress had two small tears in the fabric.

In an interview on 10/21/13 at 12:40 p.m. with S25EDTech, she stated room #5 had been cleaned by her and was ready for admission of a new patient. S25EDTech said the floors in the rooms were not mopped or swept between patients except when needed. S25EDTech then verified there was a medicine vial cap and 4 pieces of paper on the floor. She also verified there was 4 alcohol prep pads on a glove box. S25EDTech also verified there were two tears in the fabric of the bed mattress which made it unable to be properly sanitized. S25EDTech also said she did not clean beneath the entire mattresses when she cleaned the ED rooms, she would only lift the edges of the mattress and wipe around the frames.

Review of the hospital policies and procedures revealed no policy for cleaning the emergency department (ED) rooms between patients.

In an interview on 10/21/13 at 2:45 p.m., S2QualityDir verified the hospital had no policies for cleaning the ED rooms between patients.


2) Failing to ensure personal protective equipment was worn correctly by a member of the nursing staff in the ED for a patient on contact precautions.

Review of the hospital policy titled Transmission-Based Isolation Precautions Contact revealed in part:
Wear gown if clothing will have substantial contact with patient or environmental surfaces, items in a patient ' s room, or if the patient is incontinent, has diarrhea ...

Review of the medical record for Patient #2 revealed she had been admitted to the emergency department (ED) on 10/21/13 at 8:00 a.m. with complaints of diarrhea and cramping. The primary diagnosis was listed as Clostridium difficile colitis.

An observation on 10/21/13 at 12:45 p.m. of Patient #2 ' s room in the ED revealed she had a sign posted on the door stating she was under contact precautions. Further observation with S26Education revealed S27RN was at Patient #2 ' s bedside touching the patient and the bedrail. The disposable gown S27RN was wearing was observed to be draped loosely across her front and open and untied across the back.

In an interview on 10/21/13 at 12:48 p.m. with S26Education, she verified the protective gown S27RN was wearing in Patient #2 ' s room was not worn properly to prevent contamination of her scrubs and should have been secured across S27RN ' s back.


3) Failing to ensure a pharmacy technician wore a hair covering while stocking the medication dispensing system in the cesarean section (C/S) operating room.

Review of the hospital policy titled Surgical Attire, revised 11/12 revealed in part:
1. Hair will be covered in the semi-restricted and restricted areas of the surgical suite.

In an observation on 10/22/13 at 9:01 a.m. of the C/S operating room, S28PharmacyTech was observed replacing medications in the medication dispensing system. Further observation revealed S28PharmacyTech was not wearing a hair covering.

In an interview on 10/22/13 at 9:02 a.m. with S29DirMaternalChild, she said the C/S room had been cleaned and was ready for patient use. S29DirMaternalChild also said S28PharmacyTech should have been wearing a hair covering while in the C/S operating room.


4) Failing to ensure a laboratory technician washed her hands after removing dirty gloves and before leaving the ED.

An observation on 10/22/13 at 11:10 a.m. in the emergency department (ED) revealed S30LabTech performed venipuncture (obtained blood from a vein with a needle) on a patient in room #3. S30LabTech then removed her gloves and left the ED. S30LabTech did not wash her hands or use hand sanitizer after removing her gloves.

In an interview on 10/22/13 at 11:11 a.m. with S24DirCriticalCare, she stated S30LabTech should have washed her hands when she removed her gloves.


5) Failing to ensure an isolation room on the psychiatric unit was properly cleaned for patient use.

Observation of the seclusion room on the psychiatric unit on 10/22/13 at 4:00 p.m. revealed 6 pieces of a white, chalky substance and white dust underneath the mattress in the room.

In an interview with S22DirPsych, she said the isolation room had been remodeled over three months ago and sheetrock work had been done. S22DirPsych said the white pieces of chalky material and white dust under the mattress appeared to be sheetrock pieces and dust. S22DirPsych said she thought the room was ready for patient use and should have been cleaned properly.

6) failing to ensure compliance with the hospital's Employee Health Program for TB screening for 1 physician (S32MD) out of 4 physician files reviewed and for 1 employee (S6Dir SurgicalServices) out of 6 employee files reviewed.

A review of the TB Screening Policy for Physicians, provided by S16InfectionControl, revealed that physicians shall adhere to Infection Control Policy and Procedures. A review further revealed that physicians with a positive PPD skin test would be required to have a chest x-ray. A review of the Infection Control Employee Health Program, provided by S16InfectionControl, revealed that new hires would be required to have a PPD skin test upon hire

A review S32MD personnel and credential file revealed that S32MD was appointed to the Medical Staff for a 2 year period from 09/25/12 - 08/31/14. A review of S32MD personnel file revealed a TB Screening Policy form signed and dated by S32MD on 07/16/12 indicating that S32MD had a positive PPD and further indicated that a chest x-ray was required. A further review of S32MD personnel file revealed no documented evidence of a chest x-ray.

A review of the personnel file of S6DirSurgicalServices revealed a hire date of 12/17/12. A further review of S6DirSurgicalServices personnel file revealed no documented evidence of a TB Screening skin test upon hire.

In an interview on 10/23/13 at 1:30 p.m. with S16InfectionControl she indicated that she had reviewed S32MD personnel file and S6DirSurgicalServices personnel file. S16InfectionControl indicated that S32MD did not have the required chest x-ray and she further indicated that S6DirSurgicalServices did not have the required PPD skin test upon hire.

Based on observations, interviews and record reviews the facility failed to ensure that the Surgical Services Department implemented and enforced Surgical Services' policies in accordance with acceptable standards of surgical patient care by failing to enforce the facility's Infection Control Policy and the facility's Surgical Services Policies and by failing to implement and enforce the acceptable standards of surgical patient care in accordance with the AORN (Association of Peri-Operative Registered Nurses) Perioperative Standards and Recommended Practices. This failed practice was evidenced by:
1) home laundering of surgical attire,
2) warm up jackets not being completely snapped up by staff when in semi restricted or
restricted areas,
3) surgical staff wearing undergarments that extended above the scrub top neckline and
below the sleeve,
4) sterile packaged items being stored in the equipment room,
5) the sterile field left unattended before the surgical procedure had begun,
6) the use of warmed I.V. solutions during surgical procedures not consistent for all surgical
procedures

Findings:
A review of the Infection Control Policy, provided by S16InfectionControl, as the most current, indicated that the Surgical Services Department will adhere to the AORN Perioperative Standards and Recommended Practices.

In an interview on 10/22/13 at 10:10 a.m. with S6DirSurgicalServices she indicated that the Surgical Services Department adhered to the AORN Perioperative Standards and Recommended Practices.

A review of the "2013 AORN Perioperative Standards and Recommended Practices", Section C: Standard of Perioperative Nursing, Scope of Perioperative Nursing Practice, indicated that Perioperative RN's use AORN recommended practices as a foundation for practice and specialized educational preparation.

This failed practice was evidenced by:
1) home laundering of surgical attire
A review of the Surgical Services Policy - Surgical Attire, provided by S6DirSurgicalServices, as the most current, indicated that the policy's reference was: AORN Recommended Practice for Perioperative Nursing (2009). The policy further indicated that surgical attire for surgical services personnel will be home laundered and that physicians will be provided surgical attire by the hospital.

A review of the 2013 AORN Perioperative Standards and Recommended Practices: Surgical Attire, Recommendation V revealed that surgical attire should be laundered in a health care-accredited laundry facility. It further revealed that home laundering can not be monitored for quality, consistency or safety, home laundering may not meet the specified measures necessary to achieve a reduction in microbial levels in soiled surgical attire and home laundering has been shown to be less effective for cleaning surgical attire.

In an interview on 10/22/13 at 10:10 a.m. with S6DirSurgicalServices she indicated that the Surgical Services Policy - Surgical Attire had not been updated to reflect the 2013 AORN Perioperative Standards and Recommended Practices:

2) warm up jackets not being completely snapped up by staff when in semi restricted or
restricted areas ,
An observation of the Surgical Services Department on 10/22/13 observed staff wearing warm up jackets that were not snapped up when in the semi restricted areas (S12RN), wearing long unsnapped scrub gowns as warm up jackets (S14SurgTech) and not wearing snapped up jackets (S13RN) when performing circulating duties in a bilateral total joint surgical procedure.

A review of the 2013 AORN Perioperative Standards and Recommended Practices: Surgical Attire, Recommendation III.b. revealed that all non-scrubbed personnel should wear a long-sleeved warm up jacket snapped closed with the cuffs down to the wrists to prevent the edges of the front of the jacket from contaminating a skin prep area or the sterile surgical field and to prevent skin squames shed from bare arms.

In an interview on 10/22/13 at 9:00 a.m. with S11RN and S12RN they indicated that they were not aware of 2013 AORN Perioperative Standards and Recommended Practices: Surgical Attire, Recommendation III.b. regarding warm up jackets and that they were allowed to wear their warm up jackets unsnapped.

In an interview on 10/22/13 at 10:10 a.m. with S6DirSurgicalServices she indicated she was not aware of 2013 AORN Perioperative Standards and Recommended Practices: Surgical Attire, Recommendation III.b. regarding warm up jackets. She further indicated that she did not have a Surgical Services Policy addressing warm up jackets.

3) surgical staff wearing undergarments that extended above the scrub top neckline and
below the sleeve,
In observations of the Surgical Services Department on 10/22/13 staff (S11RN) were observed wearing undergarments that extended above the scrub top neckline and below the sleeve.

A review of the 2013 AORN Perioperative Standards and Recommended Practices: Surgical Attire, Recommendation III.b.1 revealed that all personal clothing should be completely covered by surgical attire. It further revealed that undergarments that extended above the scrub top neckline or below the sleeve of the surgical attire should not be worn as personal clothing is not laundered by a health care-accredited laundry facility.

In an interview on 10/22/13 at 9:00 a.m. with S11RN and S12RN they indicated that they were not aware of 2013 AORN Perioperative Standards and Recommended Practices: Surgical Attire, Recommendation III.b.1. regarding all personal clothing should be completely covered by surgical attire. They further indicated that staff were allowed to wear undergarments that extended above the scrub top neckline or below the sleeve of the surgical attire as long as the undergarments were black or white.

In an interview on 10/22/13 at 10:10 a.m. with S6DirSurgicalServices she indicated she was not aware of 2013 AORN Perioperative Standards and Recommended Practices: Surgical Attire, Recommendation III.b.1. regarding undergarments that extended above the scrub top neckline or below the sleeve of the surgical attire should not be worn She further indicated that she did not have a Surgical Services Policy addressing the wearing of undergarments in the Surgical Services Department.

4) sterile packaged items being stored in the equipment room,
In an observation on 10/22/13 of the Surgical Services Department equipment room and non sterile supply room were noted sterile packaged instruments and sterile packaged supplies stored on top of the Panandoscopy Cart, the Arthroscopy Cart and the G-I Cart, as well as, sterile packaged instruments and sterile packaged supplies inside of these open carts on top of other equipment.

A review of the Infection Control Policy, provided by S16InfectionControl as the most current, indicated that protection in the form of covers or housing shall be provided to protect the integrity of critical (sterile) items.

A review of the Surgical Services Department Policy titled: "Event Related Sterility Maintenance", provided by S6DirSurgicalServices, as the most current, indicated that all sterilized items will be stored in an appropriate cabinet or shelf in a clean area and items that remain on storage shelves for varying lengths of time will be placed in plastic dust covers. It further indicated that sterile items should be handled as little as possible and stored in limited access areas.

A review of the 2013 AORN Perioperative Standards and Recommended Practices: Sterilization, Recommendation XV indicated that sterilized items should be stored in a manner to ensure sterility and should be stored in closed cabinets or covered carts with limited access to the sterile supply area.

In an interview on 10/22/13 at 9:00 a.m. with S11RN and S12RN they indicated that the equipment room stored most of the unsterile equipment used by the surgical personnel for their surgical procedures and that there would be a lot of traffic in and out of that equipment room each day.

In an interview on 10/22/13 at 10:10 a.m. with S6DirSurgicalServices she indicated that the sterile packaged items should not be stored on the carts in the equipment room.

5) the sterile field left unattended before the surgical procedure had begun,
In an observation on 10/22/13 of the Cystoscopy surgical suite, it was noted that the sterile field was opened in preparation for a surgical procedure. It was further noted that no one was present in the Cystoscopy surgical suite to monitor the sterile field.

In an interview on 10/22/13 at 9:00 a.m. with S11RN and S12RN they indicated that the surgical technician had left the room to obtain needed supplies for the upcoming surgical procedure that was scheduled for that room and that no one was present in the room at that time.

A review of the Surgical Services Department Policy titled: "Aseptic Practice and Sterile Technique", provided by S6DirSurgicalServices, as the most current, indicated that sterile fields should not be left unattended until the operative procedure was completed.

A review of the 2013 AORN Perioperative Standards and Recommended Practices: Sterile Technique, Recommendation VII, revealed that sterile fields should be constantly monitored to decrease the likelihood of a breach in sterility by unrecognized contamination by personnel or vectors (eg. insects).

In an interview on 10/22/13 at 10:10 a.m. with S6DirSurgicalServices she indicated that the sterile field should not have been left unattended.

6) the use of warmed I.V. solutions during surgical procedures are not consistent for all surgical procedures,
An observation on 10/21/13 was made of the warming cabinets in the Surgical Services Department that contained the warmed I.V. solutions.

In an interview on 10/21/13 at 11:30 a.m. with S9Anesthesia he indicated that anesthesia has available I.V. fluid warming machines for all surgical procedures that can monitor the temperature of I.V. solutions used in patient procedures. S9Anesthesia further indicated that the I.V. fluid warming machines are used during long surgical procedures or during big surgical procedures. S9Anesthesia indicated that the I.V. solutions in the warming cabinets are used by anesthesia on shorter surgical procedures (when patients require warmed I.V. solutions) due to the cost of setting up the fluid warming machines that can continually monitor the temperature of I.V. solutions during patient procedures.

In an interview on 10/21/13 at 11:55 a.m. with S10DirAnesthesiology she indicated that anesthesia has available I.V. fluid warming machines for all surgical procedures that can monitor the temperature of I.V. solutions used in patient procedures. S10Anesthesiology further indicated that the I.V. fluid warming machines are used during long surgical procedures or during big surgical procedures. S10Anesthesiology indicated that the I.V. solutions in the warming cabinets are used by anesthesia on shorter surgical procedures (when patients require warmed I.V. solutions) due to the cost of setting up the fluid warming machines that can continually monitor the temperature of I.V. solutions during patient procedures.

A review of the 2013 AORN Perioperative Standards and Recommended Practices: Safe Environment of Care, Recommendation XIII, revealed that policies and procedures for the provision of a safe environment of patient care should be developed and should be consistent to minimize patient risk for injury or complications, to standardize practice and to direct all Perioperative personnel.