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Based on policy review and interview, the facility failed to ensure the information given to patients regarding filing a grievance included contact information for the state agency.

Findings include:

Review of the facility policy #2865, "Patient Complaint, Discrimination, and Grievance", with and effective date of 7/27/12, revealed under additional information, "Complainants have a right to contact the Department of Health Services Office for Civil Rights or the State Attorney General, or the state health department."

Review of the information given to patients on admission revealed a dissatisfaction and grievance procedure. The information included the number for the consumer health assistance for the state. The information did not include contact information for the state agency.

On 11/16/12, the Director of Quality was interviewed and confirmed the state agency contact information was not listed in the grievance procedure.

Based on record and policy review the facility failed to ensure appropriate type of restraints were used per facility policy for 1 of 30 patients (Patient #18).

Findings include:

Patient #18 presented to the Emergency Department (ED) on 7/7/12 at 7:37 PM, with general complaints of not feeling well. The patient was diagnosed with alcohol intoxication and later discharged, at 9:19 PM, to the authorities.

Review of the Emergency Room Final Report indicated while Patient #18 had walked in to ED, the patient had indicated she could no longer walk and was put in a wheel chair. The patient was also noted, to have been making attempts to flip herself out of the wheel chair, smelled of alcohol, and was crying hysterically.

Review of the ED Nurses's Notes, dated for 7/7/12 and documented at 8:20 PM, documented Patient #18 attempted to fall out of bed, continued crying, was complaining about life situations (money, bills, etc...), did not respond to reassurance, and would not stay in bed even with the ED staff at the bedside. Further documentation indicated the doctor had been at the bedside, was aware of the patients's behavior, and at 8:02 PM gave a verbal order for the patient to be placed in soft restraints for patient safety.

Review of a Restraint/Seclusion Assessment indicated (by check box), Resident #18 had been put in soft restraints to all four extremities (left arm, right arm, left leg and right leg). The assessment further indicated (by check box) the patient was crying, had impulsive behavior, and the restraints were to be continued for non-violent behavior.

Review of a second ED Nurses' Notes, dated for 7/7/12 and documented at 9:01 PM, indicated Patient #18 had pulled out a second IV despite being in soft 4 point restraints and was placed in 4 point "leather" restraints. The note also indicated the patient continued to ramble about life, had expressed she wanted to go home, but continued to demonstrate unsafe behavior.

Review of Patient #18's remaining ED record, including physician orders and restraint assessments, failed to reveal an order for "leather" restraints or that an updated restraint assessment had been completed.

During an interview with an emergency room RN, Employee #6, on 11/16/12, the nurse reported a physician's order was always obtained when a patient was placed in restraints.

Review of the facility's policy number 12414, titled Restraint Use in Non Violent Situations, with the effective date of 1/31/12, under the sub-section III. Policy, indicated the following: "... I. Restraint Availability: Soft limb restraints, mittens that are tied, bed side rails, and Freedom Splints (where available) and enclosed beds (where available) will be the only restraints available for use for non-violent situations..."

Based on record review and staff interview, the facility failed to obtain a physician's order to initiate four point restraints on a patient (Patient #30).

Findings include:

Patient #30

Patient #30 presented to the emergency room of the facility on 7/10/12, with diagnoses including alcohol intoxication, altered mental status, suicide attempt, shoulder pain and arthritis.

Record review revealed Patient #30 was brought in to the emergency room by Emergency Medical Services (EMS) after drinking for three days. The family reported they found empty bottles of Valium, Hydrocodone and Cyclobenzeprine and believed the patient could have consumed the medications. The patient was described as being combative during transport to the hospital.

Record review revealed Patient #30 was assessed by Registered Nurse (RN) Employee #8, at 11:49 PM and was described as being agitated and combative. Record review revealed the use of restraints was initiated on 7/11/12, at 12:05 AM due to the patient's attempts to remove "lines, dressings, or equipment". The Restraint Initiation Form dated 7/11/12 indicated the patient was restrained due to non violent behavior. The form revealed the physician was notified of a change in the patient's condition.

Review of the Restraint/Seclusion Assessment Form dated 7/11/12 at 1:00 AM, revealed Patient #30 was in four point soft restraints due to verbal threatening towards others, physical threatening towards others and attempts to remove lines, dressings or equipment. The patient was described as physically violent.

Record review revealed Patient #30 remained in four point restraints for violent behavior until 7/11/12 at 7:02 AM.

Record review revealed there was no evidence of a physician's order or physician's verbal order for restraint use, however, a physician note dated 7/11/12 at 1:00 AM revealed the physician did see Patient # 30 within the hour of restraint initiation. The physician's note did not identify the encounter with the patient as a face to face evaluation but did describe the patient's behavior and need to continue restraints.

During an interview with RN, Employee #3 on 11/15/12, the nurse reviewed Patient #30's record and was unable to find a physician's order for restraint.

During an interview with an emergency room RN, Employee #6, on 11/16/12, the nurse reported a physician's order was always obtained when a patient was placed in restraints.

Review of the facility's policy and procedure entitled "Restraint Use in Violent Situations" original effective date 5/1/10, current effective date 11/2/12 revealed the nurse was to obtain a written or documented verbal order prior to the initiation of restraint or seclusion. The policy and procedure revealed "If the need for restraint or seclusion occurs so quickly that an order cannot be obtained prior to the application of the restraint or seclusion, the order must be obtained either during the emergency application of the restraint or seclusion or immediately after (within a few minutes) the application of restraint or seclusion".

Based on record review and staff interview, the facility failed to monitor patients placed in restraints for 2 of 30 patients (Patients #30, #29)

Findings include:

Patient #30

Patient #30 presented to the emergency room of the facility on 7/10/12, with diagnoses including alcohol intoxication, altered mental status, suicide attempt, shoulder pain and arthritis.

Record review revealed Patient #30 was brought in to the emergency room by Emergency Medical Services (EMS) after drinking for three days. The family reported they found empty bottles of Valium, Hydrocodone and Cyclobenzeprine and believed the patient may have consumed the medications. The patient was described as being combative during transport to the hospital.

Record review revealed Patient #30 was assessed by Registered Nurse (RN) Employee #8, at 11:49 PM and was described as being agitated and combative. Record review revealed the use of restraints was initiated on 7/11/12, at 12:05 AM due to the patient's attempts to remove "lines, dressings, or equipment". The Restraint Initiation Form dated 7/11/12 indicated the patient was restrained due to non violent behavior. The form revealed the physician was notified of a change in the patient's condition.

Record review revealed there was no evidence of a physician's order or physician's verbal order for restraint use, however, a physician note dated 7/11/12 at 1:00 AM revealed the physician did see Patient # 30 within the hour of restraint initiation. The physician's note did not identify the encounter with the patient as a face to face evaluation but did describe the patient's behavior and need to continue restraints.

Review of the Restraint/Seclusion Assessment Form dated 7/11/12 at 1:00 AM, revealed Patient #30 was in four point soft restraints due to verbal threatening towards others, physical threatening towards others and attempts to remove lines, dressings or equipment. The patient was described as physically violent.

Review of the Restraint/Seclusion Assessment Form dated 7/11/12 at 2:07 AM, revealed Patient #30 remained violent and continued to be verbally and physically aggressive. The patient remained in four point soft restraints. The form indicated the restraints were checked/loosened.

Review of the Restraint/Seclusion Assessment Form dated 7/11/12 at 3:39 AM, revealed Patient #30 continued to be in four point restraint and remained violent. The form revealed the patient was provided with bathroom/elimination, hygiene needs, and restraints were checked/loosened.

Review of the Restraint/Seclusion Assessment Form dated 7/11/12 at 4:29 AM, revealed Patient #30 remained in four point restraints for violent behavior. The patient received range of motion and the restraints were checked and loosened.

Review of the Restraint/Seclusion Assessment Form dated 7/11/12 at 5:35 AM, revealed Patient #30 remained in four point restraints for violent behavior. The patient was repositioned and restraints were checked and loosened.

Review of the Restraint/Seclusion Assessment Form dated 7/11/12 at 6:32 AM, revealed Patient #30 remained in four point restraints. The patient's restraints were checked/loosened.

Patient #30 was released from the four point restraints at 7:02 AM.

During an interview with RN, Employee #3, on 11/15/12, the nurse reviewed Patient #30's record and was unable to find evidence of more frequent checks of Patient #30 while in four point restraints. The RN confirmed the facility restraint policy required the nurse to check patients in restraints for violent behavior every fifteen minutes.

A request was made to speak to RN, Employee #8, however, the employee was reported to have been terminated.

During an interview with an emergency room RN, Employee #6, on 11/16/12, the nurse reported patient's who were in restraints for violent behavior were to be checked and documented by nursing staff every 15 minutes.

Review of the facility policy and procedure entitled "Restraint use in Violent Situations" original date 5/1/10, current effective date 11/1/12, revealed "Monitor the patient for appropriateness and necessity of restraints or seclusion, restraint safely applied, risks associated with the intervention, level of distress or agitation, cognitive status and vital signs if able to obtain." The policy and procedure revealed that patients in restraints must be monitored a minimum of every 15 minutes, more frequent or continuous depending on assessment of the patient.



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Patient #29

Patient #29 was admitted to the facility on 6/24/12 with suicidal ideation.

Review of Patient #29's record revealed the patient was put in restraints for violent behavior at 1:40 PM on 6/24/12. The nurse documented "criteria for release not met".

Monitoring the restraints was documented at the following times:

2:14 PM, violent behavior. Criteria for release not met.
3:00 PM, violent. Criteria for release not met.
4:35 PM, non-violent behavior. Continued reason for restraint use.

The nurses documented non-violent behavior at 5:00 PM, 6:00 PM, and 7:00 PM.

At 7:15 PM, 8:00 PM, 9:00 PM, 10:00 PM, and 11:00 PM, the nurse documented violent behavior, criteria for release not met.

At 11:59 PM and 12:58 AM, the nurse documented non-violent behavior.

At 2:23 AM, 2:54 AM, 4:00 AM, 5:15 AM, and 6:16 AM, the nurse documented violent behavior, and to continue the restraints, criteria for release not met.

The restraints were discontinued at 7:09 AM.

On 11/16/12, an emergency room registered nurse (RN) was interviewed and reported when she had a patient in restraints, the patient was usually placed in the room across from the nursing station for direct observation. The RN reported the department often used sitters to sit with patients in restraints. The RN reported she would document the status of the patient in restraints every 15 minutes.

Based on clinical record reviews, observations and interviews, the facility failed to ensure nursing staff developed and kept current nursing care plans specific for each patient for 10 of 30 patients (Patient #26, #4, #5,#6, #7, #13, #28 #12, #20 and #28).

Findings include:

Patient #26

Patient #26 was admitted to the facility on 11/14/12, with chief complaints of back pain, leg swelling, cough and shortness of breath. The history and physical completed 11/14/12 indicated history of cervical and uterine cancer, thyroid cancer, hypertension, anxiety disorder, chronic back pain and spasm due to degenerative joint disease (DJD). The physical exam revealed healing/scabbing over shingles lesions on the coccyx area of the back. The physician dictated that Patient #26 was crying and anxious during the exam and the physician indicated it was difficult to get a history. Lab tests showed a low platelet count (15,000). Normal levels were 150,000 to 450,000.

The physician recommended a plan for the following:
1) Pain control with fentanyl patches (a narcotic), Soma and Baclofen (muscle relaxants). Physician orders included Xanax (for anxiety), Soma, Two Lidocaine transdermal patches, 700 milligrams (mg), Morphine 0.4 mg intravenous push as needed for pain and Oxycodone 10/325mg for pain.
2) Thrombocytopenia (low platelets) needing further tests, required transfusions and steroids. The physician expressed a concern that due to the low platelets and the hypertension, bleeding in the head may occur.
3) Patient #26 was allergic to Aspirin, Codeine and Naproxen.

Observation of Patient #26 during med pass on 11/15/12, revealed Patient #26 was feeding herself and able to open containers. There were visible multiple bruising from venipunctures (a risk of the low platelets) and Patient #26's verbal responses were slurred. An attempt to recline Patient #26 so the Lidocaine patches could be applied to the back resulted in increased discomfort. Patient #26 requested to be able to sit up and lean forward to allow the application of the Lidocaine patches.

The only care plans that were currently in Patient #26's chart were generic regarding falls and oxygen saturations, such as wearing non-skid socks and having the call light within reach. There were no individualized interventions regarding Patient #26's needs. Specific care plans regarding pain management, including possible source being healing Shingles lesions, bleeding/bruising risks, or the multiple allergies to name a few problems were not created.

Patient #4

Patient #4 was admitted to the facility on 11/13/12, with the primary diagnosis of acute cerebral vascular accident (stroke). Review of the clinical record on 11/14/12, revealed the only care plan was for fall risks, which included generic interventions such as ensuring the call light was within reach and the use of non-skid socks. There was nothing specific in the care plan that related to Patient #4.

Patient #5

Patient #5 was admitted on 11/13/12, with a primary diagnosis of trans ischemic attack. Review of the clinical record on 11/14/12, revealed no care plan initiated.

Patient #6

Patient #6 was admitted on 11/11/12 with cellulitis of the left knee, and allergies to Aspirin, Avapro, Haldol, Lisinopril, and Thorazine. Review of the care plans revealed no specific interventions regarding the cellulitis of the knee, limited mobility, pain, positioning, multiple allergies or comfort measures.

Patient #7

Patient #7 was admitted to the facility following a fall at home, resulting in a fractured hip. Other diagnoses included uncontrolled hypertension and anemia. Patient #7 had an open reduction, internal fixation to repair the fractured hip. Review of the care plans revealed a fall risk/ mobility, but did not include any indication Patient #7 just had surgery to repair the hip as a reason this was identified. The actions were generic, such as making sure the call light was in reach and Patient #7 wore non-skid socks. There was no care plan initiated regarding the surgical repair, incision care or observation, pain management, or teaching needs.

Patient #13

Patient #13 was admitted to the facility, with the primary diagnosis of diabetic ketoacidosis and required direct admission to intensive care. Additional diagnoses included infection/abscess in the groin and thigh. History and physical indicated Patient #13 had a 20-30 pound weight loss in the two weeks prior to admission and had been adjusting her own insulin without medical direction.

Review of the care plans revealed a generic care plan for fall risk and nutrition. The care plans did not include specific interventions regarding the weight loss, diabetic teaching, wound care, pain management, limited mobility related to the abscess or discomfort in the thigh and groin or discharge management of diabetes and insulin management.

An interview with the Director of Nursing on 11/15/12, confirmed the facility was aware the care plans were not adequate for patients, following a Joint Commission survey. A staff meeting was conducted on 10/18/12, and included instruction to nursing staff the care plans were the responsibility of the nurses assigned to each patient, and goals and interventions needed to be specific. A tip sheet was given to staff which included updating existing problems every shift. The Director of Nursing acknowledged the current care plans were generic.




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Patient #28

Patient #28 was admitted to the facility on 8/22/12, with diagnoses including numbness in the tongue and face, chronic pain, mild dysphagia and dyslipidemia. The patient was discharged from the facility on 8/24/12.

Record review revealed Patient #28 did not have a nursing plan of care during her stay at the facility.

During an interview with Registered Nurse #3 on 11/15/12, the nurse reviewed Patient #28's clinical record and confirmed no nursing care plan was written for the patient.




23119

Patient # 12

Patient #12 was admitted to the facility on 10/30/12 with a diagnosis of acute pancreatitis and diabetes mellitus. Review of Patient #12's record failed to reveal a care plan for diabetes mellitus or pain management.

Patient #12 did have a care plan for nutrition. The care plan was limited to the intervention of a liquid diet.

Patient #20

Patient #20 was admitted to the facility on 10/8/12 with diagnoses including diabetes mellitus, right foot pain, and hypertension. Review of Patient #20's record revealed the patient had a transmetarsal amputation of the right foot on 10/11/12.

Review of Patient #20's record revealed the patient's diabetes mellitus was "poorly controlled." There was no care plan for diabetes mellitus. There was no care plan for wound care after the surgery on the right foot.

On 11/15/12, the Registered Nurse Clinical Information Specialist was interviewed and reported the system required an abnormal skin assessment to trigger a care plan for wound care.

Based on record review and staff interview, the facility failed to develop a policy and procedure addressing medications eligible and not eligible for scheduled dosing times.

Findings include:

The following facility policies and procedures were reviewed:

· Medication Administration (effective date 5/1/2011)
· High Risk High Alert Medications (effective date 5/1/2012)
· Medication Management (effective date 9/7/11)
· Processing Provider Orders: Inpatient and Outpatient (effective date 9/21/12)
· Medication Orders (effective date 5/1/12 )

Review of the policies and procedures revealed they did not specifically address the timing of medication based on the nature of the medication and the clinical application or to ensure safe and timely administration. The policies and procedures did not address medications eligible and not eligible for scheduled dosing times or identify time critical scheduled medications. The policy and procedures did not address the evaluation of medication administration timing policies, including adherence to them.

During an interview with Registered Nurse (RN) #3, confirmed the facility did not have a policy and procedure addressing time critical medications and reported the facility was currently working on a policy to address the issue.

Based on a review of the laboratory look-back procedure, the laboratory failed to have a system which included all required actions to be taken when the laboratory was notified that blood or blood components it had received were at increased risk of transmitting HIV or HCV.

Findings include:

The laboratory had a system in place to take action when notified of the receipt of blood or blood components at increased risk of transmitting HIV or HCV. However the written policy did not meet current federal regulatory requirements.

Based on record review and interview, the facility failed to ensure initial nutritional screenings captured the need for a dietician consult for 1 of 30 patients (Patient #20).

Findings include:

Patient #20

Patient #20 was admitted to the facility on 10/8/12 with diagnoses including right foot pain, diabetes mellitus, and hypertension. Record review revealed the patient's diabetes mellitus was "poorly controlled".

Record review revealed Patient #20 had a nutritional screning done on admission, which triggered no flags for a dietician consult. Five days after admission, Patient #20 remained in the hospital and an alert was autogenerated for the dietician to see the patient. The dietician saw the patient on 10/15/12.

On 11/15/12, the facility dietician was interviewed and reported she was unable to see every patient as she worked 24 hours a week. The dietician confirmed she would like to see patients with the diagnosis of diabetes mellitus, congestive heart failure, and pancreatitis, but those diagnoses did not trigger a consult.

Based on observation, interview and document review, the facility failed to monitor the temperature conditions in the Point of Care testing areas.

Findings include:

There was no documentation of room temperatures consistent with the manufacturer's temperature requirements for the performance of laboratory tests and the storage of laboratory supplies in the Point of Care testing and storage areas for glucose testing in the following areas: Medical/Surgical Unit, Intensive Care Unit, Nursery, Emergency Department and Surgery.

Based on interview and document review, the facility failed to ensure that policies and procedures put in place to control infections and communicable diseases of patients and personnel were followed.

Findings include:

During a site visit to the Point of Care testing locations in the facility, the nurses questioned on the floor in Medical/Surgcial and Nursery were unable to correctly state when the glucometers needed to be cleaned as was clearly defined in section VI of procedure #10540 LifeScan Blood Glucose Monitor, which stated, "The CDC (Centers for Disease Control) guidelines say to disinfect the meters after each patient use unless the meter is dedicated to the patient."


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Labor and Delivery Department

On 11/13/12, during the initial tour of the Labor and Delivery Department, at approximately 11:00 AM, the following observations were made:

- Soiled Utility Room: Dried blood was observed on the wall next to the sink, in the sink and on the alcohol-based hand cleaning dispenser. In addition, dried blood could be seen on multiple instruments that had previously been cleaned and left to dry on a non-disposable chux pad on the counter next to the sink.

- Nursery: A used pair of reusable bandage scissors was left out at the hand washing sink.

The Labor and Delivery observations were discussed and re-examined with one of the Registered Nurses (RN), who acknowledged the findings. The RN indicated the instruments were from the night before. The RN further indicated she was not sure what the bandage scissors had been used for.

Intervenous (IV) Line Insertion

On the morning of 11/14/12, while observing one of the Medical/Surgical Units' RNs insert an IV line, the RN was observed picking up a bloody piece of gauze with her bare hands, after which she disposed of the gause in a biohazard container.



23119

Pre-Operative area

On 11/14/12, in the pre-operative unit, two suction canisters were observed to have dried residue in the bottom of the canister. A staff nurse was interviewed and reported she did not know of any time the suction had been used. The staff nurse removed the dirty suction canisters and replaced them with clean canisters.

Based on medical record review and interview, the facility failed to ensure a discharge planning evaluation was completed, for one patient (Patient #26).

Findings include:

Patient #26

Patient #26 was admitted to the facility on 11/14/12, from the jail, with chief complaints of back pain, leg swelling, cough and shortness of breath.

An entry by the discharge coordinator on 11/15/12, revealed the patient was not interviewed, only a chart review was conducted. The review indicated the patient's prior functional status was independent and the prior living situation was "prison". The "anticipated discharge plan indicated the only choices were 1) Acute facility, 2) Prison.

Interviews with the social worker and the discharge coordinator on 11/16/12 at 10:30 AM, revealed:
1) The patient was not interviewed "because she was always sleeping". Both staff acknowledged they did not report to the nursing staff the patient was not able to be woken up, or attempt to schedule an interview with the patient when she would be awake
2) Neither the social worker and the discharge coordinator were able to verify the reasons the patient had been incarcerated prior to this hospitalization.
3) Both the social worker and the discharge coordinator acknowledged Patient #26 had been released from jail (no longer under arrest) when she was admitted, which would result in Patient #26 being released back into the community rather than back to the jail.
4) At the time of this interview, both the social worker and the discharge coordinator acknowledged Patient #26 may be transferred to another hospital for further evaluation but acknowledged they would not be able to tell a receiving hospital much about Patient #26's discharge needs.

Based on review of credentials of the Director of Respiratory Services, the facility was unable to produce evidence that the Director of Respiratory Services met the qualifications for director.

Findings include:

The respiratory director's credentialing file did not contain any information regarding the director's education, experience and specialized training in respiratory care to supervise and administer the service properly.