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Based on credential file review the Hospital failed to ensure that registrations were keep current for one of two practitioners.

Findings included:

The Pulmonary Nurse Practitioner's credential file was reviewed. During the review it was determined that the State Controlled Substances Registration had expired on 1/29/10.

The Hospital's Risk Manager was notified and, after following up confirmed the State Controlled Substances Registration had expired.

Based on observation and documentation review the Hospital failed to ensure that: 1). one of nine patients who had tracheostomies had a secondary tracheostomy tube at the bedside for emergent situations, and 2). one of 8 medication closets were locked.

Findings included:

1). A tour of the Pulmonary Unit was conducted on 3/5/10 at 7:10 A.M. with the Unit Manager. Observation during the tour indicated that there were at least 2 respiratory carts in the corridor that contained respiratory equipment including tracheostomy tubes.

During the tour a Respiratory Therapist (RT #2) was interviewed. RT #2 reported that each patient with a tracheostomy must have an Ambu bag (provides positive pressure ventilation), an extra tracheostomy tube, and suction equipment at the bedside.

During the tour 9 patients with tracheostomies were randomly selected for observation. Observation determined that 9 of 9 patients had wall suction units and equipment available. Nine of 9 patients had Ambu bags at the bedside. One of 9 patients did not have an extra tracheostomy tube at the bedside in case of an emergent situation.

2). A second tour of the Pulmonary Unit was conducted on 3/5/10 at 1:00 P.M. at 1:00 P.M. Observation determined that each patient room contained a medication cabinet in which non-narcotic medication was stored. The cabinet was 2 tiered with the top tier for respiratory therapy medications and the bottom tier for medications administered by nursing. During the tour 8 medication cabinets were randomly checked for security. One of 8 medication cabinets checked was unlocked.

Based on documentation review the Long Term Acute Care (LTAC) Hospital failed to ensure that: 1). medical record documentation accurately reflected the dates of procedures and events and, 2). procedures performed during the Rapid Response were documented.

Findings included:

1).The medical record documentation indicated that on 11/15/09 the Patient was admitted to an acute care hospital after being found on the floor at home. The Patient developed respiratory complication and had to be intubated and placed on mechanical ventilation. The Patient was unable to be weaned from the ventilator and on 12/6/09 a tracheostomy was performed. The the tracheostomy tube was changed an 12/11/09. On 12/12/09 the Patient was admitted to the LTAC Hospital for pulmonary rehabilitation and medical management.

The Patient Care Summary Notes, dated 1/26/10, 1/29/10, 2/8/10, and 2/9/10, indicated that the Patient's tracheostomy was inserted on 11/15/09.

Review of medical record documentation indicated that on 1/22/10 the Patient suffered decreased oxygen saturation levels (SpO2; indicative of the level of oxygen in the blood) and increased blood pressure during a weaning attempt. An electrocardiogram was performed and identified abnormalities. The Patient was placed on telemetry and blood testing was performed which showed elevated cardiac enzymes. The Patient refused to be transferred to an acute care hospital and requested to be a Do Not Resuscitate. The Patient's family were notified and the Patient was educated regarding the significance of diagnostic findings.

Review of Patient Care Summary Notes, dated 2/8/10 and 2/9/10, indicated that the date of the Patient's cardiac event was incorrectly documented as 1/25/10.

2). The Respiratory Therapist (RT #2) was interviewed on 3/5/10 at 11:30 A.M. and throughout the survey. RT #2 said the Attending Physician attempted to intubate the Patient and had some difficulty so RT #2 applied cricoid pressure. RT #2 said application of cricoid pressure allowed better visibility of the airway. RT #2 said RT #2 felt the endotracheal tube go in and saw the tube fog up; an indicator it was properly inserted. RT #2 said when the end tidal capnometer (device placed to indicate presence of carbon dioxide; indicative of proper gas exchange) was attached it changed color to indicate there was carbon dioxide present; another indicator the endotracheal tube was properly inserted. RT #2 said the endotracheal tube was taped in place and the Patient was administered 100% oxygen via an Ambu bag. RT #2 said there was no resistance when the Patient was bagged. RT #2 said another RT who was present and reported observing bilateral chest expansion. RT #2 said that after the Patient was intubated 3 staff members (NP #1, NP #2, and RT #3) were asked to listen to breath sounds to confirm placement and to recite out loud their findings.

Nurse Practitioner #1 was interviewed on 3/5/10 at 10:45 A.M. and throughout the survey. NP #1 reported being the first person to listen to the Patient's lung sounds and reported that both lungs were aerating and were clear.

Nurse Practitioner NP#2 was interviewed on 3/11/10 at 3:40 P.M. NP #2 reported being the second person to listen to the Patient's lung sounds. NP #2 reported listening to both upper lobes anteriorly and they were bilaterally diminished.

Respiratory Therapist #3 was interviewed on 3/20/10 at 6:35 P.M. RT #3 reported listening to the Patient's lung sounds anteriorly which were equal and diminished.

Review of medical record documentation, dated 3/1/10, indicated that none of the above information regarding confirmation of placement of the Patient's endotracheal tube was documented in the medical record.

Based on observation and documentation review the Hospital failed to ensure that Schedule II, III, I V, and V narcotics were stored according to policy.

Findings included:

The Hospital's Policy/Procedure titled Controlled Substances indicated that all controlled substances stored outside of the Pharmacy were to be stored under double-locked conditions unless they were stored in an Automated Dispensing System. The locked medication room door counted as the first lock and the storage cabinet as the second lock.

A tour of the Pulmonary Unit was conducted on 3/5/10 at 7:40 A.M. with the Unit Manager present. Observation determined that non-narcotic medications were stored in locked units located in each patient room. Observation determined that narcotics were stored in work/supply stations (Carts #1 to #5) that were formerly medication carts. The Carts were located in the corridor throughout the Unit . Each Cart contained a first lock to secure the entire Cart. Each narcotic drawer contained a second lock.

Observation and documentation provided by the Pharmacy determined each narcotic drawer housed Schedule II, III, and IV narcotics.

During the tour Carts #1, #2, #3, and #4 were tested for security. Cart #5 was in use by a nurse at the time of the tour.

Upon testing the Carts it was determined that the first locks for Cart #1 and Cart #2 were not secured. The second locks on the narcotic drawers were secured.

The Hospital did not ensure that narcotics were under double-locked conditions per the Policy as evidenced by the fact that the the first locks for Cart #1 and #2 were not secured.

Based on observation the Hospital failed to ensure that needles/syringes were maintained in a secure area.

Findings included:

A tour of the Pulmonary Unit was conducted on 3/5/10 at 7:40 A.M. with the Unit Manager present. Observation determined that there were 5 work/supply stations (Carts #1 to #5), formerly medication carts, located in the corridor throughout the Unit . Each Cart contained a first lock to secure the entire Cart.

A tour of the Pulmonary Unit was conducted on 3/5/10 at 7:40 A.M. with the Unit Manager. Observation determined there were 5 work stations (Carts 1-5) located in the corridors throughout the Unit that were formerly medication carts. Each cart contained a lock (secure lock #1) to secure the entire cart.

During the tour Carts #1-5 were tested for security. Cart #1 and #2 were unlocked. Upon opening the drawers observation determined that there were syringes and needles in unsecured containers located in the unlocked drawers of both Cart #1 and Cart #2.

The Hospital did not ensure that needles/syringes were maintained in a secure area as evidenced by the fact that the the first locks for Cart #1 and #2 were not secured.

Based on interviews and documentation review the Long Term Acute Care (LTAC) Hospital failed to ensure that required assessment performed during tracheostomy changes were appropriately performed and/or documented for one of one patients.

Findings included:

Review of the LTAC Hospital's Policies/Procedures titled Tracheostomy Tube Changes, effective 12/08, indicated that documentation of the procedure included: condition of stoma and surrounding skin; breath sounds; oxygen saturation level (SpO2; measure of the level of oxygen in the blood); pulse; reason for tracheostomy change, and the patient's response to the procedure.

Review of the medical record documentation indicated that entries were made via electronic entries. Tracheostomy changes were documented under Respiratory Care.

Review of the medical record documentation indicated that the Patient's tracheostomy tube was changed on 3/1/10.

The Respiratory Therapist who attempted the first tracheostomy tube for the Patient on 3/1/10 (RT #2) was interviewed on 3/5/10 at 11:30 A.M. and throughout the survey. RT #2 reported attaching a portable pulse oximeter to monitor the Patient's SpO2 during the procedure.

Review of the medical record documentation, dated 3/1/10, 11:45 A.M., indicated that condition of stoma and surrounding skin, the breath sounds and breathing pattern, the SpO2, and pulse were not documented.

Based on interviews and documentation review, the Long Term Acute Care (LTAC) Hospital failed to identify that staff were not educated when the Hospital's Policy regarding tracheostomy tube changes was updated.

Findings included:

1). The Timeline of Events, dated 3/8/10 and submitted by the Director of Nursing, indicated that the LTAC Hospital's Policy regarding routine tracheostomy changes was change the tracheostomy tube every 90 days on weaning patients per physician order.

The Pulmonary Nurse Practitioner (NP #1) was interviewed on 3/5/10 at 10:15 A.M. and throughout the survey and the Respiratory Therapist who performed the Patient's tracheostomy change (RT #2) was interviewed on 3/5/10 at 11:30 A.M. and throughout the survey. The Pulmonary Nurse Practitioner and RT #2 said routine tracheostomy changes were routinely performed every 3 months.

Review of the LTAC Hospital's Policies/Procedures titled Tracheostomy Tube Changes, effective 12/08, indicated that tracheostomy tube changes were scheduled monthly unless otherwise ordered by the attending physician and routine changes did not require a physician order.

The Unit Manager was interviewed on 4/1/10 at 7:55 A.M. The Unit Manager said it was determined that education was not provided to the clinicians and medical staff when the Policy was adopted.

The Medical Director was interviewed by telephone 3/5/10 at 1:30 P.M. and throughout the survey. The Medical Director said the original policy required that routine tracheostomy changes were performed every 3 months which was acceptable practice however; the Hospital adopted the corporate policy.