HospitalInspections.org

Based on record review and interview, the facility failed to ensure that a contractor of services furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted service, in that,
4 of 4 patient's (Patient #18, #19, #20, and #21) dialysis treatments were completed using orders that allowed the dialysis nurse to choose the patient's "Blood Flow Rate" and "Ultrafiltration Goal" through range orders; and
4 of 4 patient's (Patient #18, #19, #20, and #21) dialysis treatments did not follow the dialysis physician's order for their treatment.
Findings included
Patient #18's record reflected range orders for both "Blood Flow Rate" and "Ultrafiltration Goal" on 7/12/16, 7/09/16, 7/07/16, 7/05/16, 7/02/16, and 6/30/16. Patient #18's record reflected the 7/02/16 "Blood Flow Rate" physician's order was "300-350" but the dialysis treatment documented the "Blood Flow Rate" at "275" (less than ordered) from 2:15 PM through 4:30 PM. There was no documentation found as to why the patient was not treated as the physician ordered.
Patient #19's record reflected range orders for both "Blood Flow Rate" and "Ultrafiltration Goal" on 5/17/16, 5/10/16, and 5/07/16. Patient #19's record reflected the 5/05/16 "Ultrafiltration Goal" physician's order was "3 kg" (3 kilograms which equals 3 liters of fluid) but the dialysis treatment documented the patient received 2.293 (less than 3 kg ordered) "Ultrafiltration" during the dialysis treatment. There was no documentation found as to why the patient was not treated as the physician ordered.
Patient #20's record reflected range orders for both "Blood Flow Rate" and "Ultrafiltration Goal" on 4/26/16, 4/24/16, and 4/14/16. Patient #20's record reflected the 4/21/16 and 4/19/16 physician's orders did not reflect an "Ultrafiltration Goal," but the dialysis treatments documented the patient received "Ultrafiltration" of 2.715 (more than ordered) on 4/21/16 and 2.5 (more than ordered) on 4/19/16. There was no documentation found as to why the patient was not treated as the physician ordered.
Patient #21's record reflected range orders for both "Blood Flow Rate" and "Ultrafiltration Goal" on 3/29/16, 3/17/16, and 3/15/16. Patient #21's record reflected the 3/15/16 "Blood Flow Rate" physician's order was "300-350" but the dialysis treatment documented the "Blood Flow Rate" at "400" (more than ordered) from 9:00 AM through 11:30 AM. There was no documentation found as to why the patient was not treated as the physician ordered.
During an interview on 7/19/16 ending at 5:04 PM, Personnel #1 was informed of all the above (range orders for the blood flow rates and the ultrafiltration goals and dialysis treatments that did not follow the physician orders) findings. Personnel #1 was asked to confirm the findings. Personnel #1 confirmed the findings, "I see it."
The 4/01/08, DaVita Healthcare Partners, Inc contract for dialysis services reflected, "All staff shall comply with...rules, regulations, policies and procedures..."

Based on record review and interview, the facility failed to ensure there was supervisory personnel for building of a licensed hospital to provide, when needed, the immediate availability of an RN (Registered Nurse) to provide care for any patient, in that, the 7 PM to 7 AM shift RN supervisor was assigned to two entities (the "Specialty" hospital and the "Rehabilitation" hospital) during the same 12 hour period.

Findings included

The 7/3/16 through 7/16/16 staffing schedules were reviewed. There was one RN supervisor scheduled for each 7 PM -7 AM shift.

During an interview on 7/19/16 at 9:12 AM, Personnel #2 was asked if the RN Supervisor was assigned during their shift to the "Specialty" hospital and the "Rehabilitation" hospital. Personnel #2 stated, "Yes, she is. There is a charge nurse for the Rehabilitation hospital." Personnel #2 was asked if the Rehabilitation hospital charge nurse took a patient assignment. Personnel #2 stated, "Yes." Personnel #2 was asked if the immediately available RN for the "Specialty" hospital was also the immediately available RN for the "Rehabilitation" hospital. Personnel #2 stated, "Yes." Personnel #2 was asked if the RN Supervisor would be the immediately available RN for the ICU (Intensive Care Unit), Med/Surg (Medical/Surgical), ER (Emergency room coverage) and the Rehabilitation hospital. Personnel #2 stated, "Yes."

The 2/01/14, last revised "Staffing Plan for Nursing" required, "There must be RN supervisory...to ensure, when needed, the immediately availability of a registered nurse for bedside care a patient."

Based on interview and record review, the hospital 's registered nurse (RN) did not supervise and evaluate the nursing care for 2 of 20 patients (Patient #16 and Patient #23) in that both these patients did not have initial nursing assessments upon admission.

Findings included:

Patient #16 was admitted on 04/19/16 for heart failure and was discharged on 04/25/16. Review of Patient #16's medical record did not contain an initial nursing assessment.

Patient #23 was admitted on 06/20/16 for postoperative and post-traumatic infections and was discharged on 07/13/16. Review of Patient #23's medical record did not contain an initial nursing assessment.

In an interview on 07/19/16 at 3:15 PM Personnel #39, who was with the surveyor reviewing patient medical records, confirmed that Patient #16 and #23 had no initial nursing assessments. Personnel #39 confirmed that initial nursing assessment must be conducted within 24 hours.

Based on interview and record review, the hospital did not have a discharge summary for 1 of 19 patients (Patient #11) who was discharged on 06/05/16.

Findings included:

Patient #11 was admitted on 5/14/16 for postoperative and post-traumatic infections and was discharged on 06/05/16. A review of Patient #11's medical record on 07/19/16 did not contain a discharge summary.

In an interview on 07/19/16 at 2:48 PM, Personnel #39 who was with the surveyor reviewing patient medical records confirmed that Patient #11's medical record did not contain a discharge summary.

Based on observation, interview, and record review, the hospital's designated infection officer failed to ensure that staff members adheres to infection control practices, in that:

A. 1 of 3 preoperative and postoperative staff members (Personnel #38) was not performing hand hygiene after providing direct patient care to each of the 3 patients in the preoperative area;

B. 2 of 3 staff members in the procedure room (Personnel #27 and Personnel #36) were observed wearing their mask outside the non-restricted area;

C. 1 of 1 dead cricket was observed on the floor near the entrance of the cafeteria;

D. 1 of 4 dietary staff hung her used scrub jacket in a rack where clean supplies were stored;

E. the temperatures of 1 of 2 refrigerators in the kitchen were not monitored on 07/03/16 and 07/04/16; and

F. the nurse who completed wound care on 07/18/16 for Patient #9 did not follow the hand hygiene policy to protect the patient and herself.

Findings included:

While following a tracer patient (Patient #22) on 07/20/16 the following was observed:

A. At 7:24 AM Personnel #38 was observed providing direct patient care to 3 patients in the preoperative area (Patient #22, Patient #24, and Patient #25). Personnel #38 failed to perform hand hygiene after providing care to Patient #22. Personnel #38 went to Patient #24 and took her vital signs. Without performing hand hygiene, he went to Patient #25 and obtained her vital signs. At 7:25 AM Personnel #10 was informed of the findings and she confirmed that hand hygiene should be conducted after providing direct patient care. Personnel #10 stated the facility adheres to AORN guidelines (Association of periOperative Registered Nurses).

B. At 7:22 AM Personnel #36 was observed wearing a mask in the non-restricted area (preoperative/postoperative nurse's station). At 8:20 AM Personnel #27 was observed wearing a mask in the hallway close to the nurse's station. At 8:21 AM Personnel #10 was informed of the findings and she confirmed that masks were not permitted outside the procedure room.

During a tour of the dietary area with Personnel #41 on 07/19/16 the following was observed:

C. At 11:45 AM one dead cricket was found on the floor near the entrance of the cafeteria. This observation was confirmed by Personnel #41 who phoned housekeeping to clean the said area.

D. At 11:50 AM in the dietary manager's office a used scrub jacket was hung in a rack where clean supplies were stored. In an interview with Personnel #32 at 11:50 AM she stated it was her jacket and that she uses it when entering the walk-in freezer.

E. At 11:55 AM the surveyor observed a refrigerator temperature list posted outside the refrigerator. The list was not checked on 07/03/16 and 07/04/16. This refrigerator stored "Jellos," apple sauces, and juices for patient consumption. At 11:56 AM Personnel #32 was informed of the findings. Personnel #32 confirmed the refrigerator's temperature was not checked on 07/03/16 and 07/04/16.

"PeriOperative Standards and Recommended Practices for Inpatient..." AORN 2014 edition page 56 and 63 reflected "VI.c. Surgical masks should be discarded after each procedure...Recommendation II...II.a. A handwash should be performed...before and after each patient contact..."

The hospital policy "Refrigerator Temperature Monitoring" reviewed 04/01/16 required "II. Temperature shall be checked and recorded on a daily basis..."

F. During an observation on 07/18/16 at 3:06 PM, Personnel #14 was observed during Patient #9's surgical incision dressing change. Personnel #14 removed the dressing, cleansed the site and replaced the dressing without removing gloves or washing her hands between the dirty and clean procedures/steps of the process.

During an interview on 07/18/16 at 3:06 PM, Personnel #2 and #14 were informed of the above findings. Personnel #2 and #14 confirmed he findings.

The hospital's policy "Hand Hygiene" revised on 02/01/14 required, "...wash/cleanse hands appropriately to prevent the spread of infection....direct contact with the patient...indications for hand washing and hand antisepsis...decontaminate hands after contact with patient's intact skin...with body fluids or excretions...non-intact skin, and wound dressings...if moving from a contaminated-body site to a clean-body site during patient care...hands after removing gloves..."






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