HospitalInspections.org

Based on interview and record review the facility failed to:


A. ensure on-going assessments and timely interventions were implemented in 1 of 1 patient (Patient #4) with an elevated pain level and increased blood pressure. The facility failed to ensure sufficient numbers of Registered nursing staff were available at all times in 1 of 1 Emergency Departments.
Refer to tag A0392 for additional information.

B. ensure documentation of pre/post vital signs, explanation of side effects /risk, complete the transfusion form and provide two witnesses for blood administration in 2 of 2 patients (Patient #s' 25 and 26).

Refer to tag A0409 for additional information.

Based on interview and record review the facility failed to:
A. ensure on-going assessments and timely interventions were implemented in 1 of 1 patient (Patient #4) with an elevated pain level and increased blood pressure.

Findings include:
Review of the Emergency Department nurse's notes dated 09/23/2014 revealed Patient #4 was a 50 year old male who presented at 1:33 p.m. with a diagnosis of atypical chest pain. Patient #4 had a history of hypertension, myocardial infarction and cerebrovascular disease according to the notes.
At 1:43 p.m., Patient #4 was given an acuity level of 2 and emergent was documented on the assessment. The correct documentation should be semi-emergent for an acuity level of 2. Patient #4 was documented as having an elevated blood pressure of 189/108 and a pain level of 9 out of 10 (1 being the lowest and 10 being the highest amount of pain).
At 1:50 p.m., there was nursing documentation that Patient #4 was complaining of pain in the mid-sternal area and it was not radiating.
At 1:53 p.m., an ECG (electrocardiogram) showed the patient had a normal heart rhythm.
At 2:00 p.m., the physician's assessment revealed Patient #4 had complaints of blood pressure problems. He was positive for chest pain of the mid-sternal area.
At 2:55 p.m. (over an hour after presenting), the first dose of pain medication was documented as being administered by staff. Patient #4 was given the vasodilator Nitroglycerin 0.4 milligrams sublingually (underneath the tongue) and Nitroglycerin ointment 2%, 1 inches trans dermally (on the skin). At 2:56 p.m. the pain medication Morphine 5 milligrams intravenous was given.
At 3:15 p.m., the pain level was still at a 9 and there was no documented intervention.
At 4:30 p.m. the pain level was at 8 and at 4:41 p.m. the pain medication Morphine was administered again.
The next documented pain follow-up was over an hour later at 5:57 p.m. when it had decreased to a level 5.
At 7:00 p.m., Patient #4's blood pressure was documented as still being elevated at 189/97. According to documentation the physician was notified of the elevated blood pressure and orders were received for the blood pressure medication Coreg.
During an interview on 09/24/2014 after 9:00 a.m., Staff #2 and 4 confirmed the documentation.
Review of a facility letter dated 09/25/2014 revealed the reasons for the documentation of treatment delays was an electronic medical record computer glitch. Nursing staff was not able to enter medication administration until the physician enters the order in the computerized order entry system.

Review of a policy dated 04/2014 named "Emergency Department Assessments and Documentation" revealed the following:
An Emergency Department record is a legal document of the patient care given and must be accurate and legible.
F.Interventions:
All nursing interventions including the time performed and the initials of the nurse performing the procedure will be documented.
1. List all medications given including the time, name of drug, dose, route, site and signature (electronic or written).
2. Document the response to all medications given.

B. ensure sufficient numbers of Registered nursing staff were available at all times in 1 of 1 Emergency Departments.

During confidential staff interviews the following reports were made about staffing:
*There is an issue with staffing. There are several orientees and they are not able to take a full load. After 11:00 p.m. the ward clerk leaves and at 12 midnight the house supervisor leaves. The charge nurses take patients because they are so short staffed and they also work as a house supervisor after midnight. The charge nurses have to leave the ER to go the pharmacy and perform intravenous sticks on other floors at times. They are working sometimes with 3 RNs and the nurses have to do ward clerk duties after 12 midnight also.
*From 6:00 a.m. - 11:00 a.m. there are 3 RNs in the emergency room at times. One nurse for triage and the other two take patients in the back. Sometimes the charge nurse is also the house supervisor and has to leave the floor to go to pharmacy and that leaves 2 nurses in the ED. The goal is to have 4 RNS for days and nights.

Review of the Emergency Department daily logs from 09/09-22/2014 revealed a patient census range from 50 - 71 daily.
Review of the Emergency Department Staffing Grid dated 05/22/2014 revealed the following recommendations:
6:00 a.m. -11:00 a.m., called for 3 RNs;
11:00 a.m. - 11:00 p.m., called for 4-5 RNs;
11:00 p.m. - 3:00 a.m., called for 4 RNs;
3:00 p.m. - 6:00 a.m., called for 3 RNs.
Underneath the grid was the following documentation "Orienting staff are not considered in the staffing matrix - however, their hours do fall into the same productivity category!"

Time sheets for the timeframe of 09/09-09/22/2014 were reviewed with Staff #2 on 09/23/2014 and revealed the following:
09/13/2014 there were 3 RN from 6:00 a.m. -11:00 a.m. and then from 11:00 p.m. to 6:00 A.M.;
09/14/2014 there were 3 RNs from 6:00 p.m. - 11:00 p.m. and from 11:00 p.m.-6:00 a.m. There was 2 RN.
09/15/2014 from 11:00 p.m. - 6:00 a.m. there were 3 RNs;
09/16/2014 there were 3 RNs from 6:00 p.m. - 11:00 p.m. and from 11:00 p.m.-6:00 a.m. There was 2 RN.
09/17/2014 there were 3 RNs from 11:00 p.m.-6:00 a.m.;
09/19/2014 there was 2 RNs from 6:00 a.m.-3:00 p.m. and 3 RNs from 6:00 p.m.-11:00 p.m.;
09/20/2014 there was 2 RNs from 6:00 a.m.-6:00 p.m.
09/22/2014 there was 2 RNs from 11:00 p.m. to 6:00 a.m.
There was no recommendation on the staffing grid to use 2 RNs in the emergency room. When there was 3 RNs working there was no documentation of a staffing plan for ED coverage during the timeframes the charge nurse was leaving the ED.
During an interview on 09/23/2014 after 2:00 p.m., Staff #2 confirmed she was using the staffing grid dated 05/22/2014 as a guide for staffing. She confirmed that on some shifts they only had 2 RNs working and reported she probably also covered the shifts. Staff #2 confirmed they normally worked with 3 RNs on days (6:00 a.m.-6:00 p.m.), 3 RNs on nights (6:00 p.m.-6:00 a.m.) and 1 RN from 11:00 a.m.-11:00 p.m.). The timeframes she needed coverage were from 6:00 a.m. -11:00 a.m. and 11:00 p.m. -6:00 a.m.. They recently posted jobs to hire two house supervisors.

Based on interview and record review the facility failed to ensure documentation of pre/post vital signs, explanation of side effects/risk, complete the transfusion form and provide two witnesses for blood administration in 2 of 2 patients (Patient #s' 25 and 26).
Findings include:
Review of an Emergency department (ED) nurses note revealed Patient #25 presented on 09/09/2014 at 7:27 p.m. with a diagnosis of anemia/gi(gastrointestinal bleeding). There was documentation the patient was c/o (complaining of) shortness of breath, dizziness and feeling weak x 7-10 days ...
Review of physician orders dated 09/09/2014 at 9:34 p.m. revealed LPC X1 (meaning RBC-quantity 1) and LPC X2 (meaning RBC-quantity 2). There was no documentation of the frequency of administration of the blood except the word once. Review of another physician order for blood at 9:23 p.m. read this was to be done STAT ( meaning immediately).
Review of the nurse's notes at 10:12 p.m., revealed the ERP/NP (Emergency Room Practitioner/Nurse Practitioner was notified of abnormal lab hgb (hemoglobin) 6.0 and hct (hematocrit) of 18.8.
Review of the "BHSET Blood and Blood Component Flow sheet" revealed the following:
09/10/2014
1st unit- Prior to transfusion two nurses were to sign they checked the blood off (at the bedside). This was not documented as being performed. There was documentation of the first unit being started at 0025 (3 hours after the physician order) and the first vital signs were taken at this time. They were not documented as being taken prior to starting the infusion. The infusion was completed at 3:00 a.m. (2.5 hours later) and the vital signs taken at this time. Not after the infusion to show monitoring of the side effects post transfusion.
2nd unit- Start time for the transfusion was 4:20 a.m. and the completion time was 6:35 a.m. ( 2 hours and 15 minutes later). The vital signs were taken at 6:35 a.m. and not after the infusion to show monitoring of side effects post transfusion.
3rd unit- Start time for the transfusion was at 9:00 p.m. and the first vital signs were taken at this time. They were not documented as being taken prior to starting the transfusion. The infusion was completed at 11:30 p.m. (2.5 hours later). The last set of vital signs were documented as being taken at 10:49 p.m. (41 minutes prior to stopping the transfusion). There was no documentation on the form they were taken afterwards to show monitoring of the effects of post transfusion. According to documentation on the form staff was to place the transfusion tag on an area on the form when the transfusion was complete and they failed to do this.

09/11/2014
1st unit- Prior to transfusion two nurses were to sign they checked the blood off (at the bedside). This was not documented as being performed. The one nurse who checked the blood off did not document the time she performed the checks. The transfusion start time was also not documented. The last set of vital signs was taken at 6:30 p.m. and the completion time was listed as 6:30 p.m. also (2 hours after starting). There was no documentation of vital signs being taken to show monitoring of side effects post transfusion. According to documentation on the form staff was place the transfusion tag on an area on the form when the transfusion was complete and they failed to do this.
2nd unit - Prior to transfusion two nurses were to sign they checked the blood off (at the bedside) Two nurses signed and dated, but failed to document a time. According to documentation on the form the transfusion start time was 9:05 p.m. and the initial temperature was recorded as 99.2 degrees Fahrenheit. At 9:31 p.m. the temperature was documented as being 99.2 degrees Fahrenheit. Vital signs were taken again at 9:49 p.m. and 10:14 p.m. and staff failed to take a temperature The next temperature was not documented until 10:45 p.m. (over an hour after the last one taken). According to documentation the transfusion completion date was documented incorrectly as 09/10/2014 and the time was 11:40 p.m. The last set of vitals were documented as being taken one minute after completion at 11:41 p.m. which did not allow enough time to monitor the side effects of the transfusion. According to documentation on the form staff was place the transfusion tag on an area on the form when the transfusion was complete and they failed to do this.

09/12/2014
3rd unit- Staff failed to document they checked to see if the consent was signed and failed to check if they explained the signs and symptoms of transfusion reaction. Prior to the transfusion two nurses were to sign they checked the blood off (at the bedside). Two nurses signed and dated, but they failed to document a time. The transfusion start time was 1:12 a.m. and the completion time was at 3:50 a.m. The last set of vital signs were documented as being taken at 3:50 a.m.. There was no documentation of post vital signs being taken to show monitoring of the effects post transfusion.


Review of a physician progress note dated 07/22/2014 revealed Patient #26 was a 52 year old male with a diagnosis which included acute anemia. There was documentation the plan was to type and cross and transfuse 2 units of PRBC (packed red blood cells). Recheck the hemoglobin 4 hours post and if 8.0 or less give additional 2 units of PRBC.
Review of the "BHSET Blood and Blood Component Flow sheet" revealed the following:
07/22/2014
Unit #1- Staff failed to check that the transfusion was explained to the patient and /or family and if signs or symptoms of transfusion reaction was explained. The transfusion was started at 12:20 p.m. and completed at 2:20 p.m. and there was no documentation of post transfusion vital signs on the form.
Unit #2- The transfusion was started at 5:10 p.m. and completed at 8:00 p.m. and there was no documentation of post transfusion vital signs on the form. Staff also failed to check if there was any reaction noted during the transfusion.
07/23/2014
Unit #1- The transfusion was started at 6:00 a.m. and completed at 8:00 a.m. There were no post transfusion vital signs on the form.
During an interview on 09/24/2014 after 3:00 p.m., Staff #20 and #2 confirmed the missing information.

Review of the policy named "Blood or Blood Component Therapy/Management of Transfusion Reaction" dated 03/13/2014 revealed the following:
A physician's order for blood or blood component administration is required .....
5. Take and record the patient's vital signs, including temperature prior to administration of blood or components, and after the first 50 mls of blood has infused and then hourly for the duration of the transfusion. Baseline vital signs are used for later comparisons, to determine possible transfusion reaction.
10. The RN who will initiate the transfusion will check the unit of blood against the attached transfusion P-tag with another licensed nurse. Determine that the information matches exactly. Check the patient name, date of birth, case number, blood type, Rh factor, expiration date, and blood unit number. At the patient's bedside two (2) nurses check the Blood Bank ID bracelet and compare the patient blood ID bracelet number with the matching number attached to the transfusion Ptag. Report any discrepancies to the Blood Bank immediately and do not administer the blood until the problem is corrected.
15. For adult patients adjust rate of blood to less than 25 drops/minute, in pediatric patients blood may be given via blood compatible infusion pump. Blood is ordered based on patient weight and will be delivered over the time period specified by the physician, if not specified the blood will be transfused over 4 hours ...
16. After the first 50 mls (15 minutes for pediatric patients) is transfused and no reaction is noted increase the blood flow to the prescribed rate. The transfusion must be completed within four (4) hours. The rate of transfusion depends on the patient condition and the product being transfused. Too rapid administration of blood may overload a precarious circulatory system and induce congestive heart failure and pulmonary edema. However, with severe blood loss, prompt and rapid replacement is essential.
21. Complete documentation of the transfusion on the Blood and Blood Component Flow Sheet remove the Ptag attached to the blood bag, and place the Blood and Blood Flow Sheet in the patient's chart.

Based on observation, interview and record review the facility failed to ensure expired medications were discarded and medications were labeled when opened in 1 of 1 Emergency Department.

Findings include:

During an observation on 09/23/2014 at 9:30 a.m. the following was found in the Emergency Department medication room:
*Two open bottles of the antibiotic Amoxicillin 80 cc which were not dated.
Review of Federal Drug Administration drug inserts at https://druginserts.com/lib/rx/meds/amoxicillin-46/> revealed any unused portion of the reconstituted Amoxicilling suspension must be discarded after 14 days.

*One open bottle of Humulin regular insulin without an open date.
One bottle of Humulin 70/30 which was opened on 08/15/2014.
Review of the label on the insulin revealed it expired 28 days after opening.

During an interview on 09/23/2014 after 9:30 a.m., Staff #21 and 2 confirmed the medications should be dated when opened and they confirmed some of the bottles had not been dated. They confirmed the expired bottle of insulin.

A tour of the radiology department on 9/23/2014 was conducted with staff #9 and #19. In the supply room 10 bottles of expired Barium were found on the shelf for use. The items expired on 7/2014.

Staff #19 and staff #9 viewed the items and agreed with the findings. Staff #9 removed and discarded the expired items.

The Infection Control Officer failed to report and follow up on sanitary conditions in the public and patient care areas. Failure to recognize and clean these areas properly can cause transmission of infections and communicable diseases.

A tour of the hospital was conducted on 9/23/2014 at 1:25 PM with Staff #19, 22, and 23. The following items were found:

1. The concrete containment dike under the generator was flooded with standing rain water and plants growing inside. The water was allowed to pool which can cause water borne diseases.

2. ICU room #177 the sink was found to have mineral build up on the faucet. The sink was covered in hard water stains. The sink and faucet are unable to be properly cleaned.

3. Room #2 on the medical surgical floor had a bathroom with rust on the sink, on the shower head, and shower rails.

4. Room #203(an isolation room) on the medical surgical floor had a three drawer plastic container sitting on the floor next to the patient door. The drawers had isolation gowns, gloves, and masks inside. The container drawers when opened were exposed to the contaminants on the floor.

5. Room #210 (an isolation room) on the medical surgical floor had a three drawer plastic container sitting on the floor next to the patient door. The drawers had isolation gowns, gloves, and masks inside. The container drawers when opened were exposed to the contaminants on the floor.

6. Pillows were found in an open bag lying on the floor in the clean supply room. The pillows were exposed to the contaminants on the floor.

7. Door frames in ICU, Medical Surgical, Radiology, Laboratory, and main campus hallways were missing paint exposing the metal. The door frames are unable to be wiped down and cleaned properly. This allows contaminates and rust to get under the paint.

8. The bathroom in the sleep lab had rust on the towel rack, rails, and the bathtub faucets. The faucet, rack, and rails are unable to be properly cleaned.

9. The Formica on the nurses station desk was missing in several pieces some as large as a saucer. The missing Formica exposed wood and was not able to be cleaned properly.

10. In the ICU a sink was on the wall in the hallway. Under the sink a sticky glue trap was sitting on the floor exposed. Dead bugs were found on the trap. The trap was not in an enclosed space.

Staff #19, 22, and 23 agreed with the findings above. Staff #19 spoke with the Medical Surgical Director and new bins with wheels would be used to replace the plastic bins sitting on the floor.

Staff #23 reported there was a gap in the infection control nurse role. Staff #22 had been going between two facilities and was resigning this week.