HospitalInspections.org

Based on a review of facility documentation and medical records (MR), as well as employee interview (EMP), it was determined that the facility failed to follow nursing care policies and procedures for the prevention, and control of infections for one of three isolation medical records. (MR2).

Findings include:

Review of Policy No. 100.001, "Patient's Rights and Responsibilities," revised October 2016, revealed, " ... Patient Rights and Responsibilities: 1. You have the right to respectful care given by competent personnel which reflects consideration of your personal value and belief systems and which optimizes your comfort and dignity...5. You have the right to good quality care and high professional standards that are continually maintained and reviewed ... ."

Review, at approximately 12:41 PM on January 18, 2017, of Policy No. 146.004, "Transmission-Based Isolation," revised January 2014, revealed, "Policy: It is the policy of the Bradford Regional Medical Center to utilize Standard Precautions on all patients regardless of their infection status. ... In addition, Transmission-Based Precautions will be implemented on all patients known or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens. ... Responsibility: It is the responsibility of the physician, or professional nurse to immediately place a patient in isolation precautions whenever a patient appears to have a disease requiring transmission-based isolation precautions. ... A. Nursing 1. The registered nurse assigned to the patient has the responsibility of placing a patient in isolation, posting signs and initiating all appropriate precautionary measures in conformance with the CDC's Guidelines for Isolation Precautions as soon as a patient is suspected of or diagnosed with a communicable disease. ... 2. The Infection Prevention Department will be notified and should be consulted for any questions related to appropriate isolation precautions. 3. Nursing staff will document isolation placement in nursing notes in Meditech. ... 6. Please refer to Policy 146.026 Multidrug Resistant Organisms. ... Establishing Isolation Precautions ... F. Nursing staff will be educated by Infection Prevention and they will be responsible for educating the patient, family members and visitors on appropriate precautionary measures. G. Information on the isolation techniques will be included in the individual patient care plan and patient's nursing record. ... C. Resistant bacteria judged by the infection prevention control program, based on current state, regional, and national recommendations, include but are not limited to MRSA ... ."

Review, at approximately 1:12 PM on January 18, 2017, of Policy #146.026, "Multidrug Resistant Organisms," no review/revise date provided, revealed, "... Policy: It is the policy of Bradford Regional Medical Center (BRMC) to identify patients colonized or infected with Methicillin Resistant Staph Aureus (MRSA) ... and promptly isolate them to prevent the spread of infectious organisms. Procedure: 1. Patients with a history of MRSA or other MDRO's ... will be placed in strict contact precautions upon admission. 2. Nasal swabs for MRSA will be done on all nursing home patients and other defined high-risk patients admitted to BRMC. ... 9. Admitting will notify the nursing supervisor of the MRSA/MDRO status of the patient, the supervisor will then place the patient into contact precautions on admission ... ."

Review, at approximately 12:00 PM on January 19, 2017, of a document provided by EMP3, titled, "FAQs about MRSA," no review/revise date available, revealed, "... How do I get an MRSA infection? People who have MRSA germs on their skin or who are infected with MRSA may be able to spread the germ to other people. MRSA can be passed on to bed linens, bed rails, bathroom fixtures, and medical equipment. It can spread to other people on contaminated equipment and on the hands of doctors, nurses, other healthcare providers and visitors. ... Use Contact Precautions when caring for patients with MRSA. Contact Precautions mean: ... When leaving the room, hospital providers and visitors remove their gown and gloves and clean their hands. ... ."

Review, at approximately 12:17 PM on January 19, 2017, of "Living with MRSA," no review/revise date provided, revealed, " ... Some ways that you could get MRSA: Touching the infected skin of someone who has MRSA Using personal items of someone who has MRSA, such as towels, wash cloths, clothes or athletic equipment Touching objects, such as public phones or doorknobs, that have MRSA bacteria on the surface. Being in crowded places where germs are easily spread, such as hospitals, nursing homes ... ."

1. Between 9:30 AM and 9:50 AM on January 19, 2017, an interview was conducted with EMP11. When asked if a patient is identified in the medical record for isolation precautions due to MRSA, automatically, EMP11 stated, "In the indicators, it's flagged, if you go into indicators. ... They've changed Meditech in the ED. ... Before it came up automatically ... for them [staff] to provide to the unit when they [patients] come up [are admitted]... Now we have to tag them and pull up the intervention [for isolation]."

2. Review of MR2 on January 19, 2017, at 10:49 AM revealed a face sheet dated must ensure that isolation precautions are followed and that the information is provided to the receiving nurse on the inpatient unit. October 8, 2016, and timed at 9:36, which indicated, "Isolation: MRSA-Conta [Contact]." The first isolation note was dated October 10, 2016, at 1:38 PM.

3. During an interview on January 19, 2017, at 11:30 AM, EMP3 confirmed that there was no evidence that the patient was in isolation until October 10, 2016, at 1:38 PM. EMP3 stated that there were several opportunities that the staff could have and should have documented the MRSA history and need for isolation precautions for MR2. EMP3 indicated that the registration clerk is responsible for reviewing the patient's history and ensuring that the face sheet contains the isolation precautions required. He/she is then is responsible for placing the face sheet in a red folder. The Emergency Department nurse must ensure that isolation precautions are followed and that the information is provided ot the receiving nurse on the inpatient unit.

Based on a review of facility documentation and medical records (MR), as well as facility tour and employee interviews (EMP), it was determined that the facility failed provide care in a safe setting to a patient in one of one medical records (MR2).

Findings include:

Review, at approximately 10:05 AM on January 18, 2017, of Policy #100.006, "Assisting Patients with Communication Needs (including Non-English Speaking)," revised March 2016, revealed, "... e) At the time of the initial patient encounter with either registration or nursing, or anytime thereafter, if a deaf, visual, translation or other communication problem is identified, the patient will be offered the assistance, devices and services needed to insure adequate communication. ... 3) Procedure: All patients will be assessed upon admission for any communication barriers or considerations. ... f. Staff awareness of patient's special needs: 1. Familiarize yourself with services/equipment available and offer the assistance needed to the patient at the time of initial assessment. 2. Flag the patient's chart and care plan. 3. Place a sign over the patient's bed to inform hospital staff of patient's special needs. ... ."

Review of Policy No. 100.001, "Patient's Rights and Responsibilities," revised October 2016, revealed, "... Patient Rights and Responsibilities: 1. You have the right to respectful care given by competent personnel which reflects consideration of your personal value and belief systems and which optimizes your comfort and dignity ... 5. You have the right to good quality care and high professional standards that are continually maintained and reviewed. ... 14. You have a right to receive care in a safe setting. ... 19. You have the right to be communicated to in a manner that is clear, concise and understandable. If you do not speak English or you have a hearing, vision, speech or cognitive impairment, you will have access to an interpreter or given any needed assistance. ... ."

1. Review of MR2 on January 19, 2017, at approximately 11:00 PM, revealed that there was no documentation that a breath-activated call bell/communication device was provided to the patient.

2. Between 9:30 AM and 9:50 AM on January 19, 2017, an interview was conducted with EMP11. When asked if the patient is alert and oriented, EMP11 stated, "[He/She] is. [He/She's] verbal. When [he/she] uses a call system or something like that, we have a call system that's able to come up to [his/her] mouth. ... [He/She] blows into it with [his/her] mouth." EMP11 added, "Its [breath-activated call system] not located on the unit, so they [staff] have to request it from the sterile processing department. ... Any time after hours, they [staff] would contact the nursing supervisor to locate the equipment [in the sterile processing department] to bring it to the unit." When asked how patient needs would be handled prior to obtaining the breath-activated call system, EMP11 stated, "They [staff] can request it. We have a supervisor in house ... after hours. ... Any time that [he/she] [patient] came in [breath-activated call system] could be requested." When asked if there would be documentation in the patient's medical record of when the breath-activated call system would have been obtained for the patient, EMP11 stated, "Probably not." EMP11 added, "We have it in a bin. ... We have one unit ... all the pieces are put together and it is kept in one place [in the sterile processing department]." When asked to clarify if in the time between admission and obtaining the breath-activated call system, there is a plan for identifying patient needs, EMP11 stated, "There is not. ... [He/She] really doesn't move that much. ... Cause I don't even think that [he/she] could use the dinger bell or something like that. ... The only thing we really have ... is that one blow unit." When asked if there is a way to track when the breath-activated call system is obtained from the sterile processing department, EMP11 stated, "If the supervisor signed it out on the log ... I'm not sure that that was something that we specifically logged out. ... It goes to the specific patient and then it goes back to sterile for cleaning. ... They [nursing supervisor] may have [logged it]." When asked if between admission and obtaining the breath-activated call system, the patient would have had the ability to notify staff of immediate needs, EMP11 stated, "I would say no, probably, because how else would you be able to alert staff. ... I don't know when that unit was open how full it was [census]. ... On that unit, that's the small unit, there's only nine rooms. ... So nursing staff is up and down that unit, when it's open, a lot. ... Barring yelling, [he/she] would not have had any other reason [method to call]. ..." When asked if the patient would have had call bell accommodations in the ED, EMP11 stated, "Actually, it should have been communicated from the ED to the floor ... that [he/she] would not have had a call bell available to [him/her]." EMP11 clarified that during the hours when the patient was admitted, report from the ED for inpatient admission would have been, "... Nurse to supervisor." EMP11 added that, "Any equipment that the patient needs to have available immediately when they come to the floor, they [ED staff] are supposed to communicate it to the floor." When asked to clarify that it would have been the nursing supervisor's responsibility to obtain the breath-activated call system prior to the patient's arrival on the nursing unit, EMP11 explained that, "If they [nursing supervisor] were notified that the patient needed that [breath-activated call system]." When asked if there is any type of indication on the medical record that a call bell is available for a patient, EMP11 stated, "I don't think on a general [assessment], ... but in the actual shift assessment, they will tell how many bed rails are up, but I don't think there is anything on a daily assessment that says the call bell is available. ... On the admission ... [it is documented] that they [patient] were educated on call bells [use]. ... [It] should have been checked [that a call bell was available]." When asked to clarify what the patient's ability would have been to obtain assistance without the breath-activated call system, EMP11 stated, "I can tell you in the room that [he/she's] [was admitted to] in, if 3 South was completely opened, the nurses station ... [he/she] would have been at the opposite end of the hall [nursing station to the patient's room]. ..." When asked to clarify if there would be any documentation in the medical record with regard to obtaining the breath-activated call system, EMP11 stated, "I don't know that ...we are going to find any documentation of that blow device that [he/she] uses. ... I don't know that we're going to find something specific that tells us when ... it arrived. ... I was actually in there and helped with [his/her] care ... so I know that it was in there ... but I can't tell you when it arrived."

Based on a review of facility policies and medical records (MR), as well as employee interviews (EMP), it was determined that the facility failed to follow the established policy to ensure that the physical findings of the physician examination were documented on the medical record, related to the presenting complaint, for one of one Emergency Department (ED) medical record (MR1).

Findings include:

Review of Policy # 6780.087, "Emergency Department Medical Record," revised December 2015, revealed, "1) Statement Of Policy: ... b) All patients with an ED record will be seen by a Physician or designee. An appropriate history and physical examination and discharge instructions will be recorded on the ED chart. ... 4) Procedure: ... e) The following information will be included in the patient's medical record: ... iii) Pertinent history of the illness or injury and physical findings including the patient's vital signs."

Review of Policy No. 100.001, "Patient's Rights and Responsibilities," revised October 2016, revealed, "... Patient Rights and Responsibilities: 1. You have the right to respectful care given by competent personnel which reflects consideration of your personal value and belief systems and which optimizes your comfort and dignity ... 5. You have the right to good quality care and high professional standards that are continually maintained and reviewed. ... ."

1. Review of MR1 revealed the patient presented to the facility ED on October 7, 2016, with complaints of frank bleeding from the perineal area and blood located in a catheter. The triage note further revealed, "This morning patient had a large blood clot in perineal area and bright red blood in Foley catheter. Staff from nursing home unable to determine if bleeding is coming from vagina or urethra."

2. Review of the nursing assessment for MR1 revealed, "Female Reproductive Systems Abnormal Bleeding Genital Discharge amount Thin Genital Discharge Color Bloody Female Reproductive Additional Information Nursing home staff reports very large blood clot in perineal area this morning. ..." The Primary Impression at discharge was documented as Cystitis with Patient instructions for "UTI Cystitis Female" documented.

3. Further review of MR1 revealed no documentation of a vaginal examination by the physician to determine the source of the patient's bleeding.

4. At approximately 10:58 AM on January 18, 2017, when asked to clarify that there was no documentation regarding vaginal examination with regard to the patient's presenting hematuria, EMP3 stated, "Let me, I just want to double check, because sometimes there's a narrative at the end of this. ... Let me double check on the record to make sure ... ."

At approximately 11:57 AM on January 18, 2017, when asked if the facility had located any documentation from EMP2 regarding assessment of the patient while in the ED, EMP3 stated, "What you have is what I have."

5. Between 2:30 PM and 2:45 PM on January 18, 2017, an interview was conducted with EMP16. When asked, if upon [his/her] review of MR1, EMP16 had identified documentation of a vaginal examination in relation to the patient's presenting complaint, EMP16 stated, "Yes, I saw no vaginal exam on the first one [ED visit] for sure. It didn't say anything, at least in [his/her] [EMP2] part about vaginal [exam]." When asked if the ED evaluation should address the patient's presenting symptoms, EMP16 stated, "Yes." When asked if MR1 would reflect documentation of the vaginal examination if it had been completed, EMP16 stated, "Yes. ... If it's not charted, it's not done." EMP16 added, "I was surprised when I heard something about vaginal bleeding [for the patient's first visit], because I didn't see anything [regarding vaginal bleeding in the physician's documentation]. Apparently you didn't either, on the record [MR1], the first one [October 7], about vaginal bleeding." EMP16 added, "We know [he/she] [EMP2] has had issues with short-cutting medical records in the past."

Based on a review of facility documents and medical records (MR), as well as employee interviews (EMP), it was determined the facility failed to document Insulin administration in accordance with hospital policies two of 15 Insulin doses ordered. (MR2).

Findings include:

Review of Policy No. 100.001, "Patient's Rights and Responsibilities," revised October 2016, revealed, "...Patient Rights and Responsibilities: 1. You have the right to respectful care given by competent personnel which reflects consideration of your personal value and belief systems and which optimizes your comfort and dignity...5. You have the right to good quality care and high professional standards that are continually maintained and reviewed ... ."

Review, at approximately 1:07 PM on January 19, 2017, of "Standard Medication Administration Times," revised January 2015, no policy number provided, revealed, "... 2) Definitions: a) Scheduled medications: Defined as medications that follow a standard, repeated cycle of frequency ... These are divided into the following categories: i) Time-Critical schedule medications: Medications whose early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect. ... b) Scheduled medications i) Scheduled medications will be administered given [sic] according to standard administration times ... viii) Insulin and/or oral hypoglycemic will be administered at 0730, 1130, 1630 daily unless otherwise specified in the physician's order ix) Basal long-acting insulin will be administered at 2100 daily unless otherwise specified in the physician's order ... d) Time critical medications: i) Those medications that fall into the following therapeutic categories: ... (4) Insulin ... ii) Time critical medications are to be administered at the time indicated when necessary (e.g. rapid-acting insulin), otherwise within 30 minutes before or after the scheduled time ... ."

1. Between 2:30 PM and 2:45 PM on January 18, 2017, an interview was conducted with EMP16. When asked what the expectation of the administration of routine medications while a patient is in the ED, EMP16 stated, "Expectation would be to ... [if the physician] know somebody, know they're diabetic...that they would get their dose [insulin], or...half of their dose ... ."

2. Review of MR2 on January 19, 2017, at approximately 11:00 AM, revealed that the patient was ordered Humalog on October 9, 2016, at 7:30 AM. The insulin was ordered to be administered with each meal and at the hour of sleep with a sliding scale, based on the patient's blood sugar level. Review of the medication administration record revealed that the Humalog was not administered at 7:30 AM on October 9, 2016; and it was not administered at hour of sleep on October 10, 2016.

3. During an interview on January 19, 2017, at approximately 11:30 AM, EMP11 confirmed that the insulin was not documented as being administered to the patient of MR2 on October 9, 2016, at 7:30 AM and on October 10, 2016, at hour of sleep.