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Based on observations during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on October 24 - 26, 2022, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on document review, observation, and interview, it was determined that for 1 of 3 (Pt #14) clinical records reviewed for restraints, the Hospital failed to ensure that the use of restraint was in accordance with the order of a physician or other licensed practitioner.


Findings include:

1. The Hospital's policy, titled "Restraint and Seclusion" (dated 3/14/2022), was reviewed on 10/26/2022 and required, "[Hospital] strives to provide patient care within a least restrictive, safe, and clinically appropriate environment ...Side rails: A side-rail is considered a restraint if it is intentionally used to restrict the patient's freedom of movement and is not easily lowered by the patient. The use of side-rails, as a sole means of restraint, will not be utilized and side-rails are not to be used as a primary means of preventing falls ...A physician or APC [Advanced Practice Clinician] order must be obtained ..."

2. On 10/24/2022 at 1:00 PM, a tour of 3 North (Orthopedic/Medical Surgical) Unit, was conducted. During the tour, it was noted in Pt #14's room, that wrist restraints were attached to the bed (not applied to the patient at that time) and all 4 side rails (full side rails) were up while Pt #14 was laying in bed.

3. The clinical record for Pt #14 was reviewed on 10/24/2022. Pt #14 was admitted on 10/22/2022, with the diagnoses of Acute UTI (urinary tract infection), frequent falls. Pt #14's Fall Risk Assessment (dated 10/22/2022), indicated that the patient was a high risk for falls.
- The Physician Orders from 10/22/2022-10/24/2022, were reviewed. The orders included 2 restraint orders. There was one order for a lap-belt, initiated on 10/23/2022 and discontinued on 10/23/2022. There was another restraint order for bilateral wrist restraints, initiated on 10/23/2022 and discontinued on 10/24/2022. However, Pt #14's clinical record lacked a restraint order for the usage of full side rails (all 4 side rails up).

4. On 10/24/2022 at approximately 1:45 PM, an interview was conducted with the 3 North Charge Nurse (E #9). E #9 stated that if full side rails are being utilized, then there needs to be a separate restraint order. E #9 reviewed Pt #14's orders and acknowledged that there was no order for full side rails.

Based on document review and interview, it was determined that for 2 of 7 patients' (Pt. #10 and Pt. # 15) clinical records reviewed for nursing assessments, the Hospital failed to ensure the registered nurse evaluated the nursing care for each patient by failing to conduct a pain reassessment after interventions.

Findings include:

1. On 10/24/2022, the clinical record for Pt. #10 was reviewed. On 10/24/2022, Pt. #10 was brought to the ED (emergency department) with a complaint of abdominal pain. On 10/24/2022 at 10:25 AM, an RN administered intravenous Morphine (pain medication) to Pt. #10 due to abdominal pain. There was no pain reassessment within one hour after administering pain medication.

2. On 10/24/2022, the clinical record for Pt #15 was reviewed. On 10/20/2022, Pt. #15 was admitted with a diagnosis of left leg pain. The physician's orders from 10/20/2022 through 10/24/2022 were reviewed and included medications for pain management e.g., Morphine Sulfate, Percocet, and Acetaminophen. Pt #15's pain assessments and MAR (medication administration record) included the following:

- On 10/20/2022 at 1:55 PM, Pt #15 was administered Percocet 10-325 mg (milligrams) for a pain score of 10/10 (10 being the worst). A pain re-assessment that was done on 10/20/2022 at 2:55 PM (1 hour later), remained at 10/10. Pt #15's clinical record lacked documentation of notification to the MD or an alternate pain intervention for unresolved pain.
- On 10/20/2022 at 8:56 PM, Pt #15 was administered Percocet 10-325 mg. The pain re-assessment was done at 11:00 PM (2 hours and 4 minutes later), not the required 1 hour re-assessment.
- On 10/23/2022 at 11:25 AM, Pt #15 was administered Morphine Sulfate 4 mg for complaint of leg pain. The pain re-assessment was on 10/23/2022 at 5:22 PM (5 hours and 57 minutes later), not the required 1 hour re-assessment.

3. On 10/25/2022, the Hospital's policy titled, "Pain Management" (effective 2/2022) was reviewed and required, "... To establish guidelines for... team members to provide patients with... effective pain management... V. Procedure... I... Reassessment of pain is ongoing and not simply a one-time event... Reassess after each intervention... 1... b. Within an hour after pain pharmaceutical intervention... J. Notify the physician... of the following: Unsatisfactory pain control after providing the ordered therapy..."

4. On 10/24/2022 at approximately 1:30 PM, an interview was conducted with E #5 (ED Nurse Educator). E #5 stated that pain reassessment should be conducted one hour after each intervention. E #5 said that it is important to follow-up on the patient's pain level to ensure adequate pain management.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on October 24 - 26, 2022, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review, and interview, it was determined that for 2 of 4 (Pt. #2 and Pt. #4) patients observed on isolation, the Hospital failed to ensure adherence to the prevention of transmission of infections by failing to ensure the required use of personal protective equipment in isolation rooms.

Findings include:

1. On 10/24/2022 at approximately 10:00 AM to 10:30 AM, an observational tour of the ICU (intensive care unit) was conducted. During the tour the following was observed:
- Inside (Pt.#2's) room there was one visitor without any PPE (personal protective equipment).
- Inside (Pt.#4's) room, there were three visitors without any PPE.
- Outside both patient's rooms there was signage indicating that the patients were on Contact and Droplet Precautions.

2. On 10/24/2022, Pt.#2's medical record was reviewed. Pt. #2 was admitted to the Hospital on 10/23/2022, with diagnoses of Hypertensive emergency, RSV (respiratory syncytial virus-contagious viral respirator infection). A physician's order, dated 10/23/2022 at 9:55 AM, included, "Contact and droplet isolation status."

3. On 10/24/2022, Pt. #4's medical record was reviewed. Pt. #4 was admitted to the Hospital on 10/22/2022, with diagnoses of non-small cell lung cancer and COVID-19 positive. A physician's order, dated 10/22/2022 at 11:50 AM, included, "Contact and droplet isolation status."

4. On 10/25/2022, the Hospital's policy titled, "Standard and Transmission -based Precautions and Isolation" (revised 10/12/2022) was reviewed and required " ... Standard and transmission-based precautions are the hallmark of infection prevention and control ... are implemented to mitigate exposure of patients, visitors, and clinicians, volunteers, contractors, and team members to infectious microorganisms ... F. Types of Isolation Precautions ... 3. Contact b) Minimum PPE (personal protective equipment): gloves and gown. 4. Droplet a) Minimum PPE ... should include eye protection, gloves, and gown."

5. On 10/24/2022 at approximately 10:35 AM, an interview was conducted with a Registered Nurse (E#8). E#8 stated that the visitors in (Pt.#4's) room refuse to wear any PPE. They are aware that the patient is positive for COVID-19 but since the patient is near end of life they want the patient to see their faces.

6. On 10/26/2022 at approximately 9:30 AM, an interview was conducted with the Infection Control Officer (E#7). E #7 stated that when a patient is on any type of isolation, all persons that enter the room must wear the required PPE to prevent the spread of infection.


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B. Based on document review, observation, and interview, it was determined that for 2 of 2 staff members (E #3 & E #4), the Hospital failed to ensure the prevention of transmission of infection by failing to ensure operating room staff members with uncovered hands and arms, did not extend their hands and arms over the sterile field while delivering sterile supplies to the sterile field. This practice potentially affects approximately 800 patients undergoing surgery each month.

Findings include:

1. On 10/25/2022, the Association of periOperative Registered Nurses (AORN) eGuidelines, copyright 2012 - 2022, was reviewed. The eGuidelines included, "Guidelines for PeriOperative Practice: Sterile Technique... 5. Opening Sterile Items... 5.4. Deliver items to the sterile field in a manner that prevents unsterile objects or unscrubbed team members from leaning or reaching over the sterile field. [Recommendation]."

2. On 10/25/2022 at 9:45 AM, an observational tour was conducted in the surgical periOperative area (OR). At 10:10 AM, in surgical suite 16, two staff members (E #3, Surgical Scrub Technician & E #4, Registered Nurse) were distributing sterile supplies on the sterile field on the back table. E #3 & #4's bare hands and arms reached over the back table's sterile field where approximately 20 sterile supplies were dropped on the sterile field, including gowns, gloves, gauze, swabs, and light handles.

3. On 10/25/2022 at 10:15 AM, an interview was conducted with the OR Manager (E #2). E #2 stated that OR staff follow AORN Guidelines and that the staff should not reach across a sterile field with uncovered hands and arms.

C. Based on document review, observation, and interview, it was determined that for 2 of 2 surgical periOperative (OR) tables (#1 in the hall outside surgical suite #17, and #2 in Surgical Suite #16), the Hospital failed to ensure the maintenance of a sanitary environment to avoid sources and transmission of infection by failing to ensure that OR tables did not contain tape and/or tape residue, which cannot be properly disinfected. This practice potentially affects approximately 800 patients undergoing surgery each month.

Findings include:

1. On 10/25/2022, the Hospital's policy titled, "Monitoring Environmental Cleaning of High Touch Surfaces: Perioperative/Intraoperative," Review/Revision Date: 12/13/2022, was reviewed. The policy required, "Purpose: Ensure proper cleaning and disinfection of Perioperative/Intraoperative environments through monitoring of the cleaning process." The policy did not address the process for removing/cleaning tape and tape residue from equipment surfaces prior to disinfection.

2. On 10/25/2022 at 9:45 AM, an observational tour was conducted in the surgical periOperative area (OR). There was a surgical periOperative (OR) table in the hall outside surgical suite #17, and another in Surgical Suite #16. Both OR tables had been cleaned/disinfected, but both contained tape and tape residue on the mat and sides of the mat. Tape and tape residue do not allow proper disinfection of the surface.

3. On 10/25/2022 at 10:15 AM, an interview was conducted with the OR Manager (E #2). E #2 stated that tape and tape residue should be removed from OR equipment.


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D. Based on observation, document review and interview, it was determined that for 3 of 3 endoscopy reprocessor machines (OER-Pro/machine used to disinfect scopes/tubes for examining the stomach) observed in the GI Lab (gastro-intestinal laboratory), the Hospital failed to ensure the prevention of the transmission of infection by failing to follow the manufacturer's recommendation regarding use of the endoscopy machine detergent (EndoQuick) in the GI Lab.

Findings include:

1. On 10/25/2022 between 9:30 AM and 10:45 AM, an observational tour of the GI Lab was conducted. At approximately 10:30 AM, in the endoscopy reprocessing room, the three open bottles of detergent (EndoQuick) used for the three endoscopy machines were not labeled with the date they were opened to indicate that the detergent was not being used past the 30-day expiration.

2. On 10/26/2022, the manufacture's literature insert titled "Olympus EndoQuick Alkaline Detergent for OER-Pro" was reviewed and required, "... Installation Instructions... Use within 30 days of opening..."

3. On 10/26/2022, the Hospital's email dated 10/25/2022, was reviewed and indicated, "... Re: Detergent for OER Machine... Documenting the date it is opened in some way is best practice to ensure you aren't using it past the 30 day expiration... (From Name of Endoscopy Support Specialist)."

4. On 10/25/2022 at approximately 10:30 AM, an interview was conducted with E #1 (GI Lab Technician). E #1 stated that she has been using the machines to reprocess the scopes. E #1 stated that the bottles of detergent should be labeled when opened. Without the date, E #1 said that she would not know when the three bottles were opened.

5. On 10/26/2022 at approximately 2:15 PM, a telephone interview was conducted with Z #1 (Olympus Technical Support). Z #1 stated that the recommendation is to use the detergent within 30 days of opening to maintain the efficacy of the detergent and to prevent contamination/infection.