HospitalInspections.org

Based on interview and record review the facility's Governing body failed to develop policies and procedures and ensure policies and procedures were enforced when,

A. The physician's and the nursing staff were using different scales to determine a patient's pain level and the safe management of the prescribed pain medications.

B. Antibiotics were not being diluted according to the pharmacy instructions, placing patients at risk of vesicant effects and destruction of tissue.

Cross refer to A0144 and A491

Based on interview and record review the facility failed to follow its Grievance policy when Patient care issues were not recorded, tracked and trended.

Findings Include:

Review of the facility provided complaints/Grievances Complaints reflected one grievance in the last 6 months.

During an interview on the afternoon of 9/18/18, in the facility conference room Staff #17, Regional Director of Regulatory stated, "We get complaints, we try to correct the concern immediately. If staff take care of the complaint, we don't record it.... We thought if they corrected it, it didn't have to be written."

The facility was not able demonstrate how the patient care complaints are tracked and trended.

Review of the facility provided policy PATIENTS GRIEVANCE AND COMPLAINT (dated October 2017) reflected, "Purpose: To establish a process to address, respond, resolve and track patient complaints and grievances.... Definitions: Complaint: An issue considered resolved by staff present when the patient is satisfied with action taken on their behalf, or the nature of the complaint does not meet the definition of a grievance.... Grievance:.... Verbal complaint... regarding any of the following:
1. The patient's care
2. Abuse or neglect,
3. Issues related to the organization's compliance with the CMS Hospital Conditions of Participation.... The data collected regarding patient grievances, as well as other complaints that are not defined as grievances will be reported through the Quality Committee.

During an interview on the afternoon of 9/18/18, on the facility's nursing units, Staff #17, Regional Director of Regulatory confirmed the findings.

Based on interview and record review the facility failed to provide care in a safe setting when the facility did not develop policies and procedures and ensure policies and procedures were enforced when,

a. Antibiotics were not being diluted according to the pharmacy instructions, placing patients at risk of vesicant effects and destruction of tissue.

b. The physician's and the nursing staff were using different scales to determine a patient's pain level and the safe management of the prescribed pain medications.

Finding include:

a. An observation on the morning of 9/18/18, on the in-patient unit, revealed Staff #17, RN removed a solution from a medication vial sitting on the night stand. The vial was marked Cefipime 2 mg. Staff #17, RN then took another 10 ml syringe and drew up normal saline from a 10ml vial, and drew up the Cefipime, for a total 10 ml. solution. The syringe was then attached to the Central Line and partially injected.

During an interview on the morning of 9/18/18, in the patient's room Staff #17, RN stated, "We used to administer the antibiotics through a piggyback.... due to the hurricane in Puerto Rico there is a shortage of saline bags. We have to dilute the antibiotics. Some patients complain it burns, so we have to administer it slowly...."

Review of the facility provided training document on the administration and mixing of the facility administered antibiotics reflected, the amount of the diluent was not listed.

During an interview on the morning of 9/18/18, in the facility medication room, Staff #1, Charge Nurse stated, "The Pyxis system shows them how much to dilute with." Staff #1 brought up the screen for the administration of Cefipime 2gm; 20 milliliters of normal saline were required for the administration.

b. Review of Patient#6's Physician's Orders dated 9/9/17 reflected, "Morphine 4 mg/ml 1-5mg (milligrams) IVP (Intravenous Push) q (every) 1 hour for pain level (4-6).

Review of the Medication Administration Record reflected Patient #6 received Morphine 4mg on 9/9/17 at 12:21am. for a pain score of 3 (CPOT Scale).

Review of the facility provided CPOT (Critical Care Pain Observation Tool) (undated) reflected The CPOT is designed to scale the pain of patents who are unable to report it themselves through objective findings.... For those patients with a CPOT score of >2: There [sic] is an unacceptable level of pain. Consider further or alternative analgesia and sedation. CRITICAL ACTIONS Regular re-evaluation is crucial to appropriate pain management."

During an interview on the afternoon of 9/18/18, in the facility conference room Staff #9, RN, Charge stated, "When the patient can't speak, the nurses use the CPOT scale...." After discussion Staff #9 confirmed that the CPOT form scale is not the same as the 1out of 10 pain scale the physicians were and are currently using.

During an interview on the afternoon of 9/18/18, in the facility conference room, Staff #16, DON confirmed the finding and stated, "We need to create a crosswalk from the CPOT to the physician's scale."

During an interview on the afternoon of 9/18/18, on the facility's nursing units, Staff #17, Regional Director of Regulatory confirmed the findings.

Based on observation, interview and record review the facility's Pharmacy failed to ensure medications were administered in a safe manner when,

a. Antibiotics were not being diluted according to the pharmacy instructions, placing patients at risk of vesicant effects and destruction of tissue.

b. A patient was allowed to keep and take home medications, at the bedside, without informing the physician or acquiring an order.

Findings include:

a. An observation on the morning of 9/18/18, on the in-patient unit, revealed Staff #17, RN removed a solution from a medication vial sitting on the night stand. The vial was marked Cefipime 2 mg. Staff #17, RN then took another 10 ml syringe and drew up normal saline from a 10ml vial, and drew up the Cefipime, for a total 10 ml. solution. The syringe was then attached to the Central Line.

During an interview on the morning of 9/18/18, in the patient's room Staff #17, RN stated, "We used to administer the antibiotics through a piggyback.... due to the hurricane in Puerto Rico there is a shortage of saline bags. We have to dilute the antibiotics. Some patients complain it burns, so we have to administer it slowly...."

Review of the facility provided training document on the administration and mixing of the facility administered antibiotics reflected, the amount of the diluent was not listed.

During an interview on the morning of 9/18/18, in the facility medication room, Staff #1, Charge Nurse stated, "The Pyxis system shows them how much to dilute with." Staff #1 brought up the screen for the administration of Cefipime 2gm; 20 milliliters of normal saline were required for the administration.

b. An observation on the morning of 9/18/18, in room #214, Patient #2 had a large bottle of Glucose tabs at the bedside table. Staff #17, RN stated, "Her family brought those in from home." When asked how does the facility record if the patient had taken any, Staff #17, RN stated, "I'm not sure." Review of the medical record did not reflect the physician was not made aware of the Glucose tablets or that the physician gave an order for the patient to take the medication or medications from home.

Review of the facility provided policy MEDICATIONS BROUGHT TO THE HOSPITAL BY PATIENTS IDENTIFICATIONS, STORAGE, AND ADMINISTRATION (dated June 2016) reflected, ".... to defined the method for securing orders if a physician orders that a patient may take his own medications.... An order must be written giving the patient the right to take their own medication in the hospital.... No medication is allowed to be kept in the patient's own room.... Physician s may indicate patient may have medication at beside...."
During an interview on the afternoon of 9/18/18, on the facility's nursing units, Staff #17, Regional Director of Regulatory confirmed the findings.

Based on observation, interview and record review the facility failed to ensure the compliance of infection control practices when,

a. A patient's Foley catheter care was not performed correctly and the Foley collection bag was placed above the hips, creating an opportunity for the urine to flow back into the bladder. (Patient #5)

b. A patient's Foley catheter collection bag was dragged on the hospital's hallway flooring during transport. (Patient #1)

c. A nurse did not wash her hands after administering a shot, and did not wipe the central catheter port prior to administering a medication. (Staff #17)


d. Nursing staff were observed carrying supplies in and out of patient rooms, placing the supplies at risk of becoming contaminated and transferred to another patient.

Findings include:

a.) An observation on the morning of 9/18/18, on the facility's inpatient unit revealed patient Ernest Reynolds receiving incontinence care. The patient's Foley catheter collection bag was laying across the patient's thighs, allowing old urine to flow back into the patient's bladder. Staff #7, LVN (Licensed Vocation Nurse) was observed wiping the soiled Foley catheter tubing toward the patient's meatus, possibly introducing bacteria toward the urethra. Staff #7 was observed wiping between the patient's thighs with a wipe and then re-wiping the catheter tubing with the same contaminated cloth. The Foley catheter tubing was not cleaned to the bifurcation. Staff #6, CNA (Certified Nursing Assistant) was observed taking a clean cloth and gently drying the patient's inner thighs and legs and then dried off the patient's penis and tubing with the contaminated drying towel.

Review of the facility provided policy Indwelling Urinary Catheter Insertion Care... (dated July 2018) reflected, "... Care of Indwelling Catheter ...Clean catheter from insertion site outward to free it from exudates and excretions.... 5. Start at the meatal junction, gently cleanse the first 1-2 inches of the urinary catheter, then stabilize the catheter with your non-dominant hand while cleaning the remainder of the catheter to the bifurcation. 6. Clean the meatus and glans. 7. Clean the shaft and scrotum 8. Clean each inner thigh in a downward motion a. Note: while performing Peri-care ensure not to retrace cleaned areas with the dirty bath cloth. B. Utilize a clean bath cloth for each of the steps listed above...."

b.) An observation on the morning of 9/18/18, on the facility's inpatient unit revealed a patient being transported in a wheelchair down the hallway. The patient's Foley catheter collection bag was noted to be touching the floor by approximately ¼ of an inch. The drainage bag was being dragged along the floor. The facility's Regional Director of Regulatory interceded and had the Foley collection bag lifted off the floor.

c.) An observation in Patient room 214 revealed Staff #17, RN draw up insulin and administered it to the patient's right upper leg. Staff #17, RN did not remove her gloves and wash her hands. Staff #17 drew up an IV antibiotic and injected it into the patient's Central Line. Staff #17, RN did not clean the central lines ports.

d.) An observation on the morning of 9/18/18, on the facility's inpatient unit revealed multiple nurses carrying supplies (unopened sterile saline syringes in their pant pockets) from one patient's room into another.

During an interview on the afternoon of 9/18/18, on the facility's nursing units, Staff #17, Regional Director of Regulatory when asked if the facility had a policy for transporting of the supplies into to multiple patient room stated, "I don't think we have a policy for the saline, we only take supplies into the rooms the patient will be using."

During an interview on the afternoon of 9/18/18, on the facility's nursing units, Staff #17, Regional Director of Regulatory confirmed the findings.