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Based on facility staff interview and record review, the facility failed to provide written information regarding informed consent and the right to formulate intensity of care directives to their responsible parties for 12 of 21 sampled patients (Patients 2, 3, 4, 6,7,10 ,11, 13, 16, 17 and 18). This had the potential for the patients' responsible parties to not be fully informed of patients rights.

Findings:

1. During clinical record review for Patients 2, 3, 16 and 17, it was noted that each had been deemed unable to make informed consent decisions by their physicians and had no preexisting advance directives or preferred intensity of care for medical treatment. These patients had responsible parties that could make such decisions for them. However there was no evidence that those responsible parties had been provided with related written material.

An interview with Social Worker 1 on 11/19/14 at 10:10 AM was conducted. She stated that she contacted the patient's representatives by phone, but did not send them written material about informed consent, advanced directives and preferred intensity of treatment.



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2. Patient 7, 10, 11, and 13's clinical records were reviewed between 11/18/14 and 11/20/14. Patients 7, 10, 11, and 13 were all deemed unable to make their own medical decisions and had responsible parties who were to make their medical decisions.

The Social Service notes were reviewed for Patients 7, 10, 11 and 13. The Social Service notes all revealed, "There is no evidence of Advance Health Care Planning...or Preferred Intensity of Treatment Form on file..."

During an interview with the Social Worker 1(SW 1) on 11/19/14, at 10:10 AM, she stated the advanced directive information is offered to the patient upon admission to the General Acute Care Hospital (GACH), however the majority of their patients were not their own responsible party and unable to make their own medical decisions. She stated the advanced directive information could be mailed to their responsible parties.







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3. On 11/18/14 a record review was conducted for Patients 4, 6, and 18. The documentation for these patients indicated that their physician had deemed them unable to make informed consent decision about their care. These patients had no advance directives or preferred intensity of care. These patients also had responsible guardians who could make informed consent decision on their behalf, however there are no written evidence, to indicate that the responsible guardians were provided with the information.

On 11/19/14 at 10:10 AM during an interview with the Social Worker 1, she stated that when patients are admitted to the Acute Unit of the facility, a packet regarding advance directive and preferred intensity of care information was given to the patient and placed in the drawer. The responsible guardian did receive any information provided to the patients

Based on observation, interview, and record review, the facility failed ensure a safe hospital setting when Gynecological instruments were observed in expired sterile packaging. This failure had the potential for infection for the General Acute Care Hospital (GACH) patients.


Findings:

During a tour of the gynecological outpatient clinic on 11/20/14, at 3:55 PM, and in the presence of Supervising Registered Nurse 1 (SRN 1), several clinic instruments in sterile packaging were observed to be outdated. SRN 1 stated the instruments were used as needed for procedures which included pap smears.

The out dated instruments were in clear packaging with hand written dates. During a concurrent interview with SRN 1 on 11/20/14, she stated the hand written date on the instruments indicated the date they were sterilized. The outdated instruments (that were sterilized more than ten years prior) were as follows:

1- large Curette - dated August 25, 2004
1- Teneculum - dated August 18, 2004
1- large Forceps - dated August 25, 2004

During an interview with the Central Supply Coordinator on 11/21/14, at approximately 8:40 AM, she stated she was not responsible for checking the clinical instrument dates, and the clinic staff should have removed them from the clinic. She confirmed if the instruments were not used, they should be removed from the packaging and re-sterilized every 5 years.

The facility policy and procedure titled, "Sterilized Procedure", dated October, 2008, showed "Shelf life of the sterilized items is 5 years from the date of sterilization."

Based on interview and record review, the facility failed to ensure a specific plans of care for 2 of 21 patients (Patient 1 and 12) were developed, followed, and kept current when:

1. For Patient 12, there was no documented skin plan of care that was specific for a leg lesion. This failure had the potential for poor skin healing.

2. For Patient 1, there was no documented plan of care to address her periorbital edema. This failure had the potential for the patient not receiving the appropriate treatment.

Findings:

1. On 11/19/14, review of Patient 12's closed clinical record, indicated she was admitted to the General Acute Care Hospital (GACH) on 10/17/14, with Esophageal Reflux (difficulty keeping food down). A review of Patient 12's nursing admission assessment showed she had "3 old scabs" to her left lower leg (shin).

Review of the Patient 12's medical record, showed a care plan with an original date of 4/30/11, and was last reviewed on 4/30/14. It showed a goal that the "Client will be free of lesions/dryness," and interventions which included to discourage the patient from picking at lesions, and document observations. The care plan did not show any revisions since 2011, nor did it show any specific information such as where the lesions were or a description of the lesions.

During an interview on 11/19/14 at 2:50 PM, Registered Nurse 1 (RN 1) stated that Patient 12 had ongoing lesions and his lesion care plans are not usually individualized. She confirmed the plan of care did not appear to have been updated and/or revised in some time.

On 11/19/14, the policy and procedure titled "Health Care Objectives and Plans", dated 06/2014, revealed that health care objectives and plans are personalized to the client and must be updated and reviewed on a regular basis and to reflect a change in the clients condition.



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2. Clinical record review for Patient 1 revealed she had diagnoses which included left periorbital cellulitis. The surveyor could not locate a care plan for this this condition.

RN 1 was asked to assist in locating Patient 1's care plan for periorbital edema. She printed a care plan with the objective listed as, "Abscess of right arm will heal without complications. Will have no complication from medical restraint, redness, abrasion, edema, poor circulation etc " This was followed by implementation steps regarding restraints with lines drawn through it and marked deleted. At the bottom of the page was "Condition: Ascess/Cellulitis of right arm" with the words "right arm" crossed out and " of face" written in.

The facility policy, " Nursing Procedure Number: 10:12 Date 6/14 HEALTH CARE OBJECTIVES AND PLANS " specified " 6. Write a objective for the identified condition. Objective must be specific and measurable for the condition " .

On 11/19/14 at 10:50 AM, RN 1 acknowledged that the objective was not specific to periorbital edema and offered that the person who made this care plan must have been rushed.

Based on interview and record review, the facility failed to write a final patient diagnosis for the 1 of 21 patients (Patient 7). This failure had the potential for decreased quality of care for Patient 7.

Findings:

On 11/19/14, Patient 7's clinical record was reviewed. It showed he was admitted to the General Acute Care Hospital (GACH) on 8/12/14 and discharged home on 8/18/14.

Patient 7's transfer summary dated 8/18/14, was signed and dated by his physician, however the space for the discharge diagnosis was left blank and incomplete.

During an interview with the Standards Compliance Coordinator (SCC 2) on 11/19/14 at 9:10 AM, she confirmed the discharge diagnosis on Patient 7's transfer summary had no diagnosis documented on it.

Based on observation, interview, and record review, the facility failed to ensure all blood culture vials were current and not expired for patient blood draws. This failure had the potential for inaccurate blood culture results and possible harm to the patients.

Findings:

During a laboratory tour on 11/20/14, at approximately 3:40 PM, three blood culture collection vials were observed to be expired. The expiration date on the vials was 10/31/14.

During a concurrent interview with a laboratory staff, she confirmed the vials were expired, and should have been removed off the shelf.

On 11/20/14, during a review of the facility policy and procedure titled, "Blood Cultures", dated Revised 2/10, it revealed, staff should verify the culture bottles are "not expired."

Based on observation, interview and record review, the facility failed to store patient nutritional shakes per manufacturer recommendations. This failure had the potential for patient illness.

Findings:

During the initial kitchen tour on 11/17/14, at approximately 2:30 PM, accompanied by the Supervising Cook (SC), several boxes of nutritional "Mighty Shakes", were observed to be thawed and stored in refrigerator number 103. There were approximately 300 individual patient shakes thawed. The shakes had manufacturer written instructions to "Keep Frozen", and "Store at zero degrees or below", written on the boxes.

During a concurrent interview on 11/17/14, with the SC, he was unable to state when the "Mighty Shakes", were taken from the freezer. The SC stated the facility had a high turnover of the shakes and that he thought they had only been in the refrigerator for a day or two.

During an interview with the Registered Dietician on 11/17/14, at approximately 2:40 PM, she stated the facility did not have a policy and procedure exclusively for the "Mighty Shakes."

On 11/17/14, the policy and procedure titled, "Milkshake Delivery", revised 6/2009, revealed milkshakes are dated with a "use by" sticker and are to be consumed by the date.

Based on observation, interview and record review, the facility failed to perform preventative maintenance on a vac-file (an electric file for toenails used in the podiatry clinic in a timely manner. This had the potential for decreased quality of care for the General Acute Care Hospital (GACH) patients.

Findings:

During an inspection of the facility podiatry clinic on 11/20/14, at approximately 3:45 PM, accompanied by Supervising Registered Nurse (SRN 1), a vac-file drill was observed in the podiatry clinic. The vac file had stickers on it that showed it was last inspected for safety in 2011, and the next inspection was "Due 12/12."

During an interview on 11/21/14, at approximately 9:05 AM, SRN 1 verified the vac-file should have had a safety test completed back in 2012, and annually after that.

On 11/21/14, the facility policy and procedure (P&P) titled, "Electrical Inspection Procedure", dated 4/04, was reviewed. The P&P revealed, "...all clinical equipment utilized shall be inspected/tested as required by various codes/enforcing agencies at intervals prescribed by these requirements."