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The facility failed to ensure compliance with the Condition of Physical Environment.
Based on a tour of the inpatient psychiatric units, review of hospital documentation and interviews with staff, the Hospital failed to identify and ensure that the physical environment was safe and subsequent to the suicide of a patient, the Hospital failed to implement immediate safety interventions to correct all environmental safety issues.
See CMS form 2567 tags A 701

Based on clinical record review and interviews for two of three sampled patients (Patient's #29 and Patient #25), with a change in condition, the clinical record lacked documentation that the responsible party was notified about a change in condition. The findings include:

a. Patient #29's diagnoses included aspiration pneumonia and Down's syndrome. A review of the nurse's notes dated 12/9/10 3PM identified that a gastrostomy tube was placed by interventional radiology and nurse's notes dated 12/10/10 at 10PM identified that Patient #29 had an episode for vomiting at which time the Physician's Assistant was notified and an abdominal CT scan was ordered. Interview with the 4N Discharger Planner on 12/20/10 at 10AM identified that Patient #29's anticipated return to the extended care facility was postponed as he/she needed to tolerate G tube feedings prior to discharge. Interview and review of the clinical record with Nurse Manager #1 identifed that the clinical record lacked documentation of family and /or responsible party notification of a change in condition. According to the Medical Staff Rules and Regulations, the responsible physician or his/her designee shall contact the patient's Legal representative immediatley to advise of a signficant change in the patient's medical status.


b. Patient #25 ' s diagnoses included pneumonia and dementia. Nursing narratives and/or flow records from 11/25/10 to 11/28/10 identified that the patient was confused yet cooperative or followed commands. Nursing narratives dated 11/29/10 on the night shift indicated that the patient was confused, uncooperative, tried constantly to get out of bed and Xanax was ordered administered at 3 AM for restlessness and anxiousness. The record lacked documentation that the patient ' s legal representative was notified of the patient ' s anxiousness/restlessness/uncooperativeness and or the need for psychotropic medication administration. Interview with MD#2 on 12/22/10 at 12:05 PM noted that increased confusion would be considered a change in the patient, that he was unaware that Xanax was ordered for administered to the patient and that Xanax would not have been his/her first medication choice to treat the patient ' s delirium. According to the Medical Staff Rules and Regulations, the responsible physician or his/her designee shall contact the patient's legal representative immediately to advise of a significant change in the patient's medical status. The hospital Patient ' s Bill of Rights identified that the purpose of the policy was to outline a mechanism to assure all patients and families were provided with information regarding their rights and included the right to be kept informed about the patient ' s health and future health.

Based on review of the clinical record and review of the facility policy, the facility failed to ensure that the care plan was revised to reflect an assessment of the patient and goal of the use of restraints for three of three patients in the ICU. The findings include the following:

a. Review of Patient #38's clinical record with the Manager indicated that the patient had been admitted on 12/9/10 with respiratory failure. Review of the clinical record indicated that the patient had required bilateral wrist restraints for the period of 12/13/10 through 12/20/10. Review of the daily care plans indicated that the patient had an active problem for safety related to risk for fall only. The daily care plans failed to reflect the need for restraints and/or any associated interventions to assist in restraint reduction.

b. Review of the clinical record with the Manager for Patient #39 indicated that the patient had been admitted on 12/14/10 with sepsis and pneumonia requiring intubation. The clinical record indicated that the patient required bilateral wrist restraints for the period of 12/16/10 through 12/20/10. Review of the daily care plans indicated that the patient had an active problem for safety related to risk for fall only. The daily care plans failed to consistently reflect the need for restraints and/or any associated interventions to assist in restraint reduction.

c. Review of Patient #40's clinical record with the Manager indicated that the patient had been admitted on 12/9/10. Review of the clinical record indicated that the patient had required bilateral wrist restraints for the period of 12/10/10 through 12/20/10. Review of the daily care plans indicated that the patient had an active problem for safety related to risk for fall only. The daily care plans failed to consistently reflect the need for restraints and/or any associated interventions to assist in restraint reduction.

Review of the facility care plan policy indicated that the nursing care plan must be updated when restraints are initiated.

Based on a review of the physician credentialing file for MD #3 and interviews with facility personnel, the facility failed to include updated credentialing documentation in MD#3 ' s credentialing file. The findings include:

During a review of the credentialing file for MD#3 a Department of Obstetrics and Gynecology delineation of privileges form dated 9/24/09 indicated MD#3 was approved for performing an abdominal hysterectomy with a proctor. A letter dated 9/28/09 indicated MD#1 was granted temporary medical staff membership with admitting and clinical privileges as listed pending completion of the credentialing process. A letter dated 12/8/09 indicated MD#3 was approved for membership and privileges with attending status with clinical privileges as listed on the privilege delineation. The letter dated 12/8/09 further informed MD#3 to reference the letter dated 9/28/09 for proctoring requirements that may apply to MD#3 ' s privileges. An operative report dated 8/26/10 indicated MD#3 was the attending physician for a total abdominal hysterectomy performed on P#22. An operative report dated 8/26/10 was dictated by MD#3 and signed administratively by MD#1. The operative report identified MD#3 was assisted by PA#1. During an interview with MD#1 on 12/22/10 at 12:45 PM, MD#1 indicated on 8/26/10 MD#3 was a full attending and did not require proctoring for this type of case. During an interview with the Director of Quality Improvement (QI) on 12/22/10 at 1:40 PM, the Director of QI indicated he/she had done further inquiring and was informed MD#3 ' s credentialing file was up to date. During an interview on 12/28/10 at 10:10 AM, the Director of QI identified that the facility was continuing to review facility documentation for updated credentialing documentation for MD#3. During an interview with the Director of QI on 12/28/10 at 1:50 PM, according to MD#3 ' s credentialing file at the time of the case MD#3 was still under proctoring status but not concurrent proctoring which would require someone be in the room with MD#3 concurrent proctoring would require a retrospective review be done. The Director of QI identified there was no evidence of a change in MD#3 ' s proctor status in the medical executive committee minutes or that a retrospective review of the case was done. Facility documentation addressing proctoring requirements indicated each newly credentialed staff member would be proctored to determine his/her technical skill level and upon final recommendation a letter shall be forwarded to the Credentials Committee by the Department Chairperson. MD#3 ' s credentialing file lacked documentation that MD#3 had been removed from proctoring status.

Based on review of the clinical record and review of the policy, the facility failed to ensure that Patient #41 was monitored per the facility policy. The findings include the following:

Review of Patient #41's clinical record indicated that the patient was started on Patient Controlled Anesthesia (PCA) on 12 /20/10 at 6:30 PM. Review of the documentation indicated that the patient had vital signs and a sedation level at 6:30 PM. Although the critical care flow sheet required documentation of hourly vital signs, the next documentation of vital signs and sedation on the PCA flow sheet was at 11:00PM, four and one half hours later. Staff failed to monitor the patients pain and/or sedation level in accordance with facility policy. Review of the facility policy indicated that on the initiation of PCA vital signs and sedation level should be monitored every 15 minutes times for one hour, every hour for 4 hours, every 2 hours for 4 hours and then every four hours. The patient should be monitored for pain level and sedation level every hour for 5 hours and then every 2 hours for 4 hours and then every 4 hours.

Based on review of the clinical record, interview, and review of facility policy, the facility failed to ensure that the treatment plan had been individualized for two patients (Patient #34 and 35). The findings include the following:

a. Review of the clinical record for Patient #34 indicated that the patient was admitted on 12/11/10 with auditory hallucinations and a self-inflicted injury. The record indicated that the patient tried to cut off his right index finger with a kitchen knife. Review of the treatment plan (TP) identified the patient ' s finger injury, however there were no interventions identified on the treatment plan. In addition, the clinical record indicated that the patient was receiving pain medication regularly for generalized arthritis pain as well as pain from his/her finger injury and pain was not included on the treatment plan. Interview with the Manager indicated that the physician is responsible for completing the first page of the treatment plan.

b. Patient #35 was admitted on 11/17/10 with bipolar disorder. Review of the treatment plan dated 11/20/10 indicated that the patient should attend the pre-determined list of groups identified for Adolescents. The treatment plan failed to specify which groups the patient should attend. The manager indicated that all patients are assigned to either attend "adolescent" or "child" groups. In addition, review of the clinical record indicated that the patient attended 13 groups during the period of 12/8/10 through 12/20/10. The Manager indicated that there are approximately 6-8 groups each day and that Patient #35 does not do well in groups and rarely attended school. Review of the TP updates of 11/24/10, 12/1/10, 12/9/10 and 12/14/10 failed to identify revisions to the TP to address the patient's individualized treatment needs.

Review of facility policy indicated that the treatment plan would be based on an assessment of the patient by each discipline. The policy indicated that each update will have a short narrative explaining the patient 's progress or lack of progress toward the identified goals and includes modifications, additions, deletions or recommendations with frequency, modality and responsible person identified.



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Based on clinical record review and review of the hospital policies for one sampled patient (Patient #21) with suicidal ideations, the clinical record lacked documentation of a comprehensive care plan. The findings include:

Patient #21 was admitted on 10/31/10 with diagnoses that included urinary tract infection and hypertension. A review of the nurse's notes dated 11/8/10 at 6PM identified that the patient verbalized a desire to die. The physician was notified and the patient was seen by psychiatry at which time medication changes were made in addition to psychiatry assessments and monitoring throughout the patients hospitalization. A review of the clinical record failed to provide evidence of a comprehensive nursing care plan related to the patient's suicidal comments, response to medications changes and/or implementation of additional interventions. A review of the Department of Nursing documentation guidelines identified that the Registered Nurse utilizes data from the assessments and develops a plan of care. S/he identifies the current patient problem, selects appropriate interventions and documents this information on the daily care plan.

Based on clinical record review, interview and review of the facility policy the facility failed to ensure that hemodialysis was administered per the physician's orders. The findings include the following:

a. The clinical record for Patient #39 identified an order dated 12/15/10 for hemodialysis with a 2,000-unit bolus of Heparin. Review of the treatment record with the Manager, dated 12/15/10 failed to identify that the Heparin had been administered. Review of the hemodialysis orders dated 12/20/10 indicated that the patient was to receive a 3 Calcium, 4 Potassium bath. Review of the treatment flow sheet indicated that the patient received a 2.5 calcium bath and for the area for Potassium a check mark was present. Interview with the RN indicated that she did give the patient the 3Calcium, 4 Potassium bath and was not sure why she did not clearly document this. In addition the orders identified "1,000 units" of Heparin for the catheter. The order failed to identify the strength of Heparin to be utilized and the amount to be instilled into each lumen of the catheter.

Based on clinical record reviews and interviews with facility personel for two of six sampled patients (Patient #54, Patient #56), the facility failed to ensure that a physician order for medication was completed prior to administration.

The findings include:

a. Patient #54 was admitted to the hospital for a nasal septal reconstruction Review and observation of the physician orders dated 12/20/10 indicated that the patient may have one dose of pain medication as per discharge prescription as follows "Percocet 2". Further observation on 12/20/10 identified that the nurse started writing an order after Percocet 2 to include 5/325mg which was incomplete. Review of hospital policy "Medication Administration" identified that all medication orders are to be complete prior to administration. Interview with the PACU nurse manager on 12/20/10 identified that the medication order written was incomplete.

b. Patient #56 was admitted to the hospital for a left shoulder arthroscopy. Review of the physician orders dated 12/20/10 identified that the patient may have one dose of pain medication as per discharge prescription with no indication of drug or dosage. Review of the PACU flowsheet dated 12/20/10 identified that the patient received Percocet for a pain level of 6/10 without an order. Review of hosptial policy "Medication Administration" identified that physicians order is required for medication administration. Interview with the PACU nurse manager on 12/20/10 identified that a physician order for medication is to be completed prior to administration.

Based on a tour of the pharmacy department, review of hospital policy and interviews, pharmacists failed to provide adequate supervision for the preparation of intravenous admixtures. The findings include:

A tour of the pharmacy was conducted on 12/21/10 at 9:30 AM with Director #1. Observation identified a glass-enclosed room and contents included bags of intravenous solutions (IV). Interview with Pharmacist #1 on 12/21/10 at 10 AM noted that pharmacy technicians would prepare IV mixtures and the mixtures would include medications withdrawn from multi-dose vials. H/she further indicated that the pharmacist would verify that the correct medication and dosage had been added to the IV bag after the medication (s) had been injected into the IV solution. Pharmacist #1 indicated that the verification of accuracy was based on an empty syringe drawn back to the level that had been previously injected and the syringe was placed next to the medication and IV bag preparation. Interview with Pharmacist #1 at this time also identified that because narcotic and chemotherapeutic medications were more critical, the pharmacist is 100% sure of the preparation accuracy because the pharmacist verifies the correct medication and dosage prior to the pharmacy technician injecting the medication into the IV bag. The hospital medication management policy directed that a licensed pharmacist must monitor all medication preparation and dispensing by non- pharmacist personnel. Only a pharmacist, or authorized pharmacy personnel under the direction of a pharmacist, shall fill and label containers from which medications are to be distributed or dispensed, make label changes or transfer medications to different containers

Based on a tour of the dietary department, observations, review of hospital policies and interviews, Dietary staff failed to ensure that food was handled safely. The findings include:

A tour of the dietary department was conducted on 12/21/10 at 11 AM.
Observations identified three catering associates and a dietary supervisor donning a baseball cap and/or Santa hat. All four employees had at least shoulder length hair that was not contained within the hair covering as they prepared trays and/or worked the food preparation area. Interview with the Dietary Manager on 12/21/10 at 11AM noted that the purpose of hair covering was to ensure that hair would not fall on or into food when working with food. The hospital uniform dress code policy directed dietary staff to wear the approved hair restraint when on duty anywhere in the kitchen yet lacked identification of the hair restraints approved. Although the policy directed that long facial hair be covered, the policy did not provide direction for long head hair.

Based on a tour of the inpatient psychiatric units with the hospital administrative and engineering staff, review of hospital documentation and interviews with staff, the hospital failed to ensure that the physical environment was safe.

On 12/20/10 at 10:00 AM, during a tour of the inpatient psychiatric units the following was observed:

a. Faucet and shower controls, sprinkler heads, door handles, ceiling tiles in the patient bathrooms and common areas that posed a potential hanging hazard and were not designed to a psychiatric/ institutional standard;
b. The Celentano1 patient lounge/kitchen lacked institutional hardware and/or policies to protect the safety of psychiatric patients with a documented risk-based assessment. Subsequent interview of hospital administrative and engineering staff revealed that no patient would be left unattended in this area for more than three minutes and during this tour seven (7) patients were observed to have been left unattended for more than ten (10) minutes. Subsequent to this observation the hospital administrative and engineering staff had clinical staff respond to this area to supervise these patients;
c. The Celentano1 handicap shower had a vinyl access ramp that was split and cracked.
d. The inpatient psychiatric units on Celentano1 & Celentano 5 had electric adjustable beds that had separate nurse call and control cords that were not secured and/or removed to prevent a patient from utilizing them as a means of hanging. Subsequent to this observation the hospital administrative and engineering staff acknowledged it was hospital policy to secure these cords and the patients must have been inadvertently transferred to the unit in theses beds. Subsequent to this interview, additional observations of the Celentano1 & Celentano 5 units revealed that all electric beds had cords that weren ' t secured. The hospital put an immediate plan of correction in place to secure and or remove all cords by the end of the day;

e. The inpatient psychiatric units sleeping rooms on Celentano1 & Celentano 5 had locked wardrobes in resident rooms that, although locked, presented a gap anround the edges of the doors and hinges posing a risk as a ligature point, and were not designed to a psychiatric standard.

Based on observations, review of hospital documentation and interviews with facility personnel, the hospital failed to ensure that daily code cart checks were completed.

The findings include:

a. During tour of the Pre-Operative and the Main OR on 12/21/10, it was observed that multiple code carts/lifepacks from October 2010-December 2010 were not checked on a daily basis. Interview with the OR Nurse Manager on 12/21/10 identified that the code carts were managed by anesthesia and are usually done daily.

b. During tour of the Main OR on 12/21/10, it was identified that the trauma cart had not been checked since 8/8/10. Review of hospital policy "Trauma Policy" and hospital practice identified that the trauma cart is to be checked bi-weekly and restocked when used. Interview with the OR nurse manager on 12/21/10 identified that the trauma cart should have been checked bi-weekly.

c. During tour of the Main OR on 12/21/10, it was observed that Flash Sterilizer #3 had no logs for its usage. Further review of another Flash Sterlizer logbook failed to indicate which sterlizer was being utlized for flashing. Review of hospital policy "Sterilization" identified that complete documentation of the printed record and the flash log book is to be completed for any flashing that is done. Interview with the OR nurse manager on 12/21/10 identified that the all flash sterilizers needed to have a logbook identifying the flashing that is done and for which patient for tracking purposes.

Based on observations and interviews, the facility failed to ensure that staff utilized appropriate infection control techniques. The findings include the following:

Observations on 12/21/10 identified RN #7, with gloves on, touching the front of a dialysis machine in use and then proceeding to a second machine without removing gloves and washing hands in between contact.

Observation on 12/21/10 identified used IV bags in the hand-washing sink. The IV bags were subsequently placed on the sink next to the faucet and staff were observed washing hands in the same sink.

Interview with the Manager on 12/21/10 indicated that staff should change gloves and wash hands after machine contact and that "dirty" items should not be placed in the hand-washing sink. Review of the facility policy indicated that gloves should be changed after contact with patient specific items.





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a. During tour of the main operating rooms on 12/21/10, it was observed that multiple operating rooms had anesthesia equipment including blades and opened ETT tubes set up prior to the rooms being cleaned between cases by enviromental services. Review of hospital policy "Operating room sanitation standards" identified that between-case cleaning is to be completed to establish a clean, safe environment for the next surgical procedure. Interview with the Infection Control Nurse on 12/21/10 identified that all operating rooms are to be cleaned prior to setting up for the next case.

b. During tour of the main operating room on 12/21/10, it was observed that in the scrub area, multiple used IV bags were hanging on the scrub sinks to drain. In addition, this area is utilized by surgeons to scrub hands prior to surgery. Interview with the OR manager on 12/21/10 identfied that used IV bags were not to be left in the scrub area.

c. Observation of the TEE room in the operating suites utilized for cleaning equipment on 12/21/10 contained multiple old manuels/supplies that were being stored. In addition, multiple suction cannisters were being stored on the floor. Interview with the OR manager on 12/21/10 identified that this room is considered a soiled room and the items would be removed.

Based on review of the clinical record, interview and review of the facility policy the facility failed to ensure that an informed consent had been obtained. The findings include the following:

Review of Patient #39's record indicated that on 12/14/10 the patient had a central line placed. Review of the consent indicated that although the patient had signed the consent there was no physician signature on the consent form.

Review of the medical bylaws indicated that the patient's attending physician is responsible for securing informed consent.

Based on clinical record review and interview for one sampled surgical patient ( Patient # 46), the clinical record lacked documentation of a post anesthesia assessment. The findings include:

Patient #46's diagnoses included Multiple Sclerosis and cervical fusion on 12/8/10. Interview and review of the clinical record with Nurse Manager # 2 on 12/21/10 at 11AM identified that the patient developed a hematoma requiring evacuation on 12/15/10. A review of the anesthesiology record dated 12/15/10 failed to reflect that a post operative anesthesia evaluation was completed. A review of the Department of Anesthesia postoperative care policy identifed that at least one post anesthesia visit will be recorded, describing the presence or absence of anesthesia related complications.