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Based on observation, interview, and record review, the facility failed to set up a procedure for the assurance that 5 (#s 20, 24, 25, 26, and 30) of 30 sampled patients, or their power of attorney, were aware of the patient's rights. Findings include:

During an observation on 4/29/19 at 1:55 p.m., in the outpatient pain and wellness clinic's waiting room, or examination rooms, there were no posted patient rights.

During a record review and an interview on 4/29/19 at 2:15 p.m., patient #s 20, 24, 25, 26, and 30's admission packets showed no documentation that the residents' had reviewed their rights. Staff member A stated the clinic lacked documentation showing patients had been given their rights. The staff member stated the patient rights were not in the admission packet, but were handed a laminated list of patient rights. Staff member A stated staff were to show the laminated form to all patients, but did not know if staff were reviewing the rights with each patient.

During an interview on 4/30/19 at 9:35 a.m., staff member B stated a copy of the patient rights should be in the patient folders given on, or prior to, admission in the hospital. The clinics should have the patients' rights hanging in the waiting room. The staff member stated patients did not sign to show awareness.

During an interview on 5/1/19 at 10:24 a.m., staff member B stated the clinics did not have patients' rights visible or posted in the building for patients to see, this was not their usual practice. The staff member stated, patients were also not given a paper form of patient rights.

During an interview on 5/1/19 at 11:35 a.m., staff member B stated the previous manager at the clinic had decided that upon request by the patient, a copy of the patient bill of rights would be provided. The Patient Rights was laminated and was used for patients to read.

Review of the facility's policy, Patient Rights, last review on 12/18, showed the facility would post information on patient rights in public areas and on upon admission. Patients would receive an information packet that included information on patient rights and responsibilities.

Based on interview and record review, the facility failed to complete a background check on 6 (A, BB, CC, DD, EE, and FF) staff members. Findings include:

During an interview and a record review of personnel files, on 5/1/19 at 3:12 p.m., staff member GG stated the facility did not do background checks if staff transferred from the affiliating hospital. Staff member GG stated management staff, if transferred from the affiliated hospital, did not always receive a background check. Review of personal files for staff member A, BB, CC, DD, EE, and FF showed no background check conducted by the hospital.

During an interview on 4/29/19 at 4:15 p.m., staff members B and T stated if any staff came from the local hospital, they did not complete a background check on those staff members. Staff member B stated if the local hospital had already completed a background check, another background check was not conducted. The affiliated hospital had a different provider number.

Review of the facility policy, Employment Process HR210, reviewed on 10/18, showed the facility's pre-employment process included background checks.

Based on interview and record review, the facility failed to ensure the use of PRN (as needed) orders for restraints were not being used on 1 (#20) of 30 sampled patients. Findings include:

During an interview on 5/2/19 at 11:30 a.m., staff members T and Z stated if a patient needed a restraint, it was the facility's policy to obtain a physician order, and complete a nursing assessments for the least restrictive restraint. If a restraint was used, the patient would need to be reassessed every four hours. Staff members T and Z stated a physician was asked to provide an order for a restraint for patient #20 on 3/19/19.

Review of patient #20's medical record showed the patient was discharged from the affiliated hospital on 3/19/19 and admitted to the facility on 3/19/19. The patient's diagnoses included traumatic brain injury. A review of patient #20's physician admission assessment and plan, dated 3/19/19, showed the patient had a craniotomy on 2/7/19 and suffered a diffuse axonal injury. The patient was confused and inappropriate, "veil bed and a 1:1 sitter for safety...and extremely impulsive behavior. Continue vail bed for safety."

Review of patient #20's Physician Order, dated 3/19/19, showed "We would like patient to have a Vail bed please."

Review of patient #20's Physicians Order, dated 3/20/19, showed, "net bed as needed for safety."

Review of patient #20's nursing assessments notes showed the patient was using an enclosed bed from 3/19/19 until 4/2/19.

Review of the facility policy, Restraint of Patients, GNC1350, reviewed on 1/19, showed a prn (as needed) provider order was not allowed.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff followed policy and procedure regarding the safe administration of medications for 2 (#s 14 and 17) of 30 sampled patients. Findings include:

1. During an observation on 4/30/19 at 10:40 a.m., in an unattended patient bay, under a pillow on top of a patient care bed, was a 50 milliliter bag of cefazolin, and an IV starter kit. There was no nurse close to the medication.

During an interview on 4/30/19 at 10:40 a.m., staff member D stated the medication under the pillow was for her next patient. She stated the next patient was patient #14. She stated she had not yet brought the patient back from the waiting room. She said she had already checked the IV bag of cefazolin out of the Pyxis for the patient, and was keeping it next to the patient bay when she brought the patient back. She stated she had left the medication unattended. Staff member D was able to cite the six rights of medication administration; she stated she would not be able to ensure the rights were followed for patient #14.

During an interview on 4/30/19 at 11:32 a.m., staff member U stated it was the expectation nurses followed the facility's policy and procedures for medication administration.

2. During an observation on 5/1/19 at 10:30 a.m., three individual pre-filled one milliliter syringes labeled tetracaine, betadine, and ropivacaine were kept in a gray emesis basin in the patient care bay. The label stated the name of the medication in the syringe, the date and time the medication was drawn up, and the initials of the individual who drew up the medication in the syringes. There was no patient in the bay, and the medications were left unattended by the nursing staff.

During an interview on 5/1/19 at 10:35 a.m., staff member N stated she did not put the pre-filled medications in the patient bay for the next patient. She stated she was not sure who placed the basin with the pre-filled eye drops in the patient care bay for the next patient. Staff member N stated the next patient they were planning to bring back was patient #17. She stated patient #17 was still in the waiting room.

During an interview on 5/1/19 at 11:15 a.m., staff member P stated the medications were pre-filled that morning by a nurse, who then labeled the medications with name of medication, date, time, and the initials of the RN who filled the syringes. She stated the syringes were then kept at the nurses station in the emesis basins for the other nurses to gather with each new patient. She stated the medications were not labeled with the intended patient's name. Staff member P stated nurses were expected to follow the facility's policy and procedure for medication administration.

During an observation and interview on 5/1/19 at 11:22 a.m., staff member O stated she did not put the three pre-filled medications in the patient care bay and was not certain who did. She stated they were kept there for the next patient. She stated the next patient, patient #17, did not actually need these medications because she was having an eye tuck and not a cataract removal. The staff member then took the emesis basin with the pre-filled medications and placed it on the counter in front of the nurses station.

During an interview on 4/30/19 at 11:32 a.m., staff member T stated it was the expectation staff follow the facility's policy and procedure for medication administration and validate the six rights of medication administration.

A review of the facility's policy and procedure titled, Medications, dated 2/18, showed, "1. Medications will be administered only upon the written/verbal/electronic order of a licensed provider with privileges at [Hospital]. Orders will be for a specific patient, including name of drug, strength, dosage, mode of administration, reason (if prn medication) and time interval. If not specified by a physician, contact physician to obtain these parameters... 6. Medications will be administered by the RN who prepares them unless mixed by the Pharmacy... 11. Medications of any type will be administered after initially reconciling the medications with the medication administration record (MAR) and the Physician's Order. The '6 rights' of medication administration will be followed. The BCMA [sic] technology assists the nurse or respiratory therapist in following the '6 rights' of medication administration; however these rights should always be followed regardless of the availability of the BCMA [sic] technology:
A. Right Patient.
B. Right Drug.
C. Right Dose.
D. Right Route.
E. Right Time.
F. Right Documentation... ."

Based on observation, interview, and record review, the facility failed to ensure an informed consent for a colonoscopy was properly executed for 1 (#11); and failed to obtain consent to treat when patients were transferred from the affiliated hospital to the facility for 4 (#20, 24, 25, and 26) of 30 sampled patients. Findings include:

1. During an observation on 4/30/19 at 1:07 p.m., staff member F confirmed with patient #11 the scheduled procedure for a colonoscopy and the sedation which would be administered during the procedure. Staff member F had the patient sign the informed consent to treat, and explained to the patient the physician performing the colonoscopy would be in before the procedure to discuss with her, the risks and benefits associated with the procedure.

During an interview on 4/30/19 at 1:10 p.m., patient #11 stated she had not met with the provider, completing the colonoscopy, to discuss the risk and benefits of the procedure. She stated she had had an annual physical on 4/5/19 with her primary care physician, but had not had the risks and benefits for the procedure reviewed with her at that appointment. She stated she had not yet been informed of the risk and benefits for the procedure by the performing physician. She stated the nurse explained a bit about the procedure and what to expect, and then she signed the consent for treatment.

Review of patient #11's Consent for Operation, Anesthetics, and Other Medical Services, showed it was signed by the patient on 4/30/19 at 1:00 p.m.

During an observation on 4/30/19 at 1:30 p.m., staff member AA reviewed the risks and benefits with patient #11 prior to the procedure. Patient #11 stated she did not have any questions regarding the procedure, and was transported to the procedure room. The patient did not re-sign the consent for treatment.

During an interview on 4/30/19 at 1:15 p.m., staff member F stated the physician had not yet reviewed the risks and benefits of the procedure with the patient. She stated they had the patient sign the informed consent for treatment and anesthesia first, then the provider would come in before the procedure and explain the risks and benefits to the patient. Staff member F stated the staff do not have time to have the patient sign the informed consent before they go back for the procedure.

During an interview on 4/30/19 at 1:18 p.m., staff member G stated patients usually would see their provider the week before their scheduled procedure to discuss the risks and benefits of the procedure, and the informed consent was obtained at that time. She stated when the patient came in for their procedure, they should already have an understanding of the procedure.

A review of the facility's policy and procedure titled, Patient Rights and Responsibilities, dated 12/18, showed, "15. Consent and Participation in Care Plan: the patient has the right to reasonable informed participation in decisions involving his/her health care: A. To the degree possible, this should be based on a clear, concise explanation of his/her condition and of all proposed technical procedure, including the possibilities of any risk or mortality or serious side effects, problems related to recuperation, and probability of success. The patient should not be subjected to any procedure without his/her voluntary, competent, and understanding consent or the consent of his/her legal authorized representative. Where medically significant alternatives for care or treatment exist, the patient will be so informed."


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2. During an interview on 5/1/19 at 4:45 p.m., staff member B stated they did not realize the facility could not use the affiliated hospital's patient's signed consent to treat form when a patient discharged from the affiliated hospital and then was admitted to the facility. The staff member realized the facility had a different provider number but stated it was the continuation of care.

During an interview on 5/2/19 at 11:00 a.m. staff member II stated the facility did not have patients fill out new consent to treat if they "transferred" from the affiliated hospital.

Review of patient #s 20, 24, 25, and 26's medical charts showed no consent to treat on or before being admitted to the facility.

Based on observation, interview, and record review, facility staff failed to ensure medications and biologicals were kept in secured or locked storage for use in patient care areas; Silver Nitrate applicator sticks, Thin Prep Pap cytology collection containers, 10% Formalin, and Viscous Lidocaine 2%. This deficient practice had the potential to affect any patient receiving care in the outpatient Women's Clinic. Findings include:

1. During an observation on 5/1/19 at 8:20 a.m., at the outpatient Women's Clinic, room 15 had an unsecured, opened, 118 ml bottle of Viscous Lidocaine 2%.

During an observation and interview on 5/1/19 at 8:24 a.m., room 16 had one unsecured cylindrical tube of ARZOL Silver Nitrate applicator #100 sticks. The word, "POISON" was written on each tube by the manufacturer. An opened, 118 ml bottle of Viscous Lidocaine 2% was also found unsecured. Staff member X stated all rooms had been "set up" the same, and each room had Silver Nitrate applicator sticks, Viscous Lidocaine, Thin Prep Pap cytology, and some rooms had Formalin. Staff member X stated new staff were taught, upon orientation, to set up each room the same way.

During an observation on 5/1/19 at 8:27 a.m., room 12 had an unsecured, opened, 118 ml bottle of Viscous Lidocaine 2%.

During an observation on 5/1/19 at 8:30 a.m., room 11 had an unsecured, opened, 118 ml bottle of Viscous Lidocaine 2%.

During an observation on 5/1/19 at 8:33 a.m., room 1 had four unsecured Thin Prep Pap cytology containers with approximately 30 mls of Cytyc solution. Each container read, "Danger/Poison" and had a picture of a skeleton and crossbones, as well as, "Caution Flammable" with a picture of a flame written on the container by the manufacturer.

During an observation on 5/1/19 at 8:44 a.m., room 2 had four unsecured Thin Prep Pap cytology containers with approximately 30 mls of Cytyc solution. Each container read, "Danger/Poison" and had a picture of a skeleton and crossbones, as well as, "Caution Flammable" with a picture of a flame written on the container by the manufacturer.

During an observation on 5/1/19 at 8:55 a.m., room 3 had five unsecured Thin Prep Pap cytology containers with approximately 30 mls of Cytyc solution. Each container read, "Danger/Poison" and had a picture of a skeleton and crossbones, as well as, "Caution Flammable" with a picture of a flame written on the container by the manufacturer. An opened, 118 ml bottle of viscous Lidocaine 2% and a container with 60 ml of 10 % Formalin was also found unsecured.

During an interview on 5/1/19 at 9:30 a.m., staff members Q and X stated an inspection had been conducted and a report was submitted regarding unsecured items in the outpatient Women's Clinic. Staff member X stated a request had been submitted on 4/10/19 to [facility name] for locking cabinets to be installed in patient rooms. Neither staff member Q nor X knew the status of the locking cabinets.

During an interview on 5/1/19 at 11:25 a.m., staff member Y stated a "Medication Storage Inspection" had been conducted on 2/6/19. Staff member Y stated she had submitted a spreadsheet, with pictures of each item, to ensure staff were securing those items in the outpatient clinics.

2. During an interview on 5/2/19 at 9:44 a.m., staff member HH stated items identified as dangerous, poisonous, or flammable, should always be kept in a secured location.

During an observation and interview on 5/2/19 at 9:56 a.m., in the outpatient Woman's Clinic, room 2 had six unsecured Thin Prep Pap cytology containers. Each container read, "Danger/Poison" and had a picture of a skeleton and crossbones, as well as, "Caution Flammable" with a picture of a flame written on the container by the manufacturer. An opened 118 ml bottle of Viscous Lidocaine 2% was found unsecured. Staff member B stated all hazardous items should have been removed from patient rooms, when discovered, immediately, or kept in a secured area.

During an observation on 5/2/19 at 10:00 a.m., room 4 had one unsecured Thin Prep Pap cytology container with approximately 30 mls of Cytyc solution. The container read, "Danger/Poison" and had a picture of a skeleton and crossbones, as well as, "Caution Flammable" with a picture of a flame written on the container by the manufacturer. An opened 118 ml bottle of Viscous Lidocaine 2% was found unsecured and a cylindrical tube of ARZOL Silver Nitrate applicator #100 sticks were also identified.

During an observation and interview on 5/2/19 at 10:03 a.m., room 8 had four unsecured Thin Prep Pap cytology containers with approximately 30 mls of Cytyc solution. Each container read, "Danger/Poison" and had a picture of a skeleton and crossbones, as well as, "Caution Flammable" with a picture of a flame written on the container. An opened, 118 ml bottle of Viscous Lidocaine 2% was found unsecured.

During an observation and interview on 5/2/19 at 10:10 a.m., in the outpatient Woman's Clinic, room 2 had six unsecured Thin Prep Pap cytology containers with approximately 30 mls of Cytyc solution. Each container read, "Danger/Poison" and had a picture of a skeleton and crossbones, as well as, "Caution Flammable" with a picture of a flame written on the container. An opened 118 ml bottle of Viscous Lidocaine 2% was also found unsecured. Staff member B stated no changes had been made to the patient rooms of the Woman's Clinic after concerns had been identified on 5/1/19.

A review of the facility's Medication Storage Inspection report, dated 2/6/19, with pictures of each item used by the clinic, read, "Comments: The drugs in the exam rooms need to be kept in a locking cupboard or drawer. I will attach a spreadsheet with a list that will help you know what is required to be locked up and what is ok to leave out. With new guidelines come procedures." Page three of the report, showed a picture of Formalin 10% solution, which read, "Must be locked at all times in pt rooms and at Nurses stations." Page four of the report showed a picture of a specimen container for Thin Prep Pap test and Silver Nitrate applicator sticks, which read, "Can be left secured behind Nurses Station but locked in pt rooms." Page five of the report showed a picture of a Lidocaine 2.5% tube, which read, "Can be left secured behind Nurses Station but locked in pt rooms."

A review of the facility's Hazard Surveillance and Infection Prevention Survey, dated 2/27/19, read, "...Plant Operations will install locks as instructed when you determine the need... In beginning process, [Staff name] has organized and noted which cabinets will need locks."

A review of the facility's policy, Hazardous Chemical Communication Program, read, "...C. Department Responsibilities... 7. Monitor storage and handling of hazardous materials/chemicals..."

Based on observation, interview, and record review, the facility failed to ensure schedule II narcotics were secured properly in the Glacier View Plastic Surgery Outpatient Clinic. This deficient practice had the potential to affect all patients who received care at Glacier View Plastic Surgery Clinic. Findings include:

During an observation on 5/1/19 at 1:00 p.m., on the wall by the nurses station in the Glacier View Plastic Surgery Clinic, was a locked glass cabinet. Inside the locked glass cabinet were #78 oxycodone 7.5/325 mg tablets and #26 Hydrocodone 7.5/325 mg tablets. The glass cabinet, with the schedule II narcotics, was not double locked.

During an interview on 5/1/19 at 1:30 p.m., staff member R stated they used the medications for patients who were having a procedure, and needed pain relief. She stated the medications were accounted for once a week, or when a medication was ordered by the provider. She stated the medications were counted with two staff members.

During an interview on 5/1/19 at 1:38 p.m., staff member Q stated they had asked for a double locking device for the schedule II narcotics, but one had not yet been provided.

During an interview on 5/1/19 at 3:25 p.m., staff member S stated all schedule II narcotic medications should be double locked and properly secured. Staff member S stated the hydrocodone and the oxycodone were scheduled II narcotics, which should have been kept in a double locked medication storage.

A review of the facility's policy and procedure titled, Procurement, Control and Storage of Medications, dated 5/2019, showed, "5. Medication Storage: B. Medications are stored under proper conditions of sanitation, temperature, ventilation, segregation and security. C. All medications are stored in lockable areas and are accessible only to personnel duly authorized, as per Policy and Procedure, to dispense and/or administer medications. D. Schedule II Controlled medications not stored in the Pharmacy are accessible only to licensed Medical, Nursing, or Pharmacy personnel... ."

Based on observation, interview, and record review, the facility failed to ensure a point of care blood glucose test was performed per facility policy and procedure for 1 (#13) of 30 sampled patients. Findings include:

During an observation on 4/30/19 at 9:36 a.m., staff member D started an IV on patient #13's right arm. The nurse received flashback from the IV insertion and advanced the IV catheter, while removing the steel needle from the patient's arm. The steel needle had an automatic safety cap which covered the tip of the steel needle when it was removed from the patient's venous access site. Staff member D placed the capped steel IV needle into a basin and set it aside. She then applied an IV dressing over the IV site, and attached the IV tubing and started the patient's IV fluids. The nurse then brought the basin with the IV needle to the other side of the patient's bed, and using a small heparinized cap tube, removed a small amount of blood from the tip of the IV flash plug. The nurse then applied the drop from the heparinized cap tube to the blood glucose test strip, and obtained a point of care blood glucose reading.

During an interview on 4/30/19 at 10:00 a.m., staff member D stated she was trained to obtain the blood sample for a blood glucose test from the IV flash plug. She stated she obtained the sample from the flash plug reservoir on the capped steel needle of the IV set. She stated she was not sure if that was the actual policy and procedure for the facility.

During an interview on 4/30/19 at 11:32 a.m., staff member U stated the facility's policy and procedure showed a blood sample for a blood glucose point of care test can be obtained from fresh blood within 30 minutes of obtaining the sample. She stated nurses were taught to complete the blood glucose test in this manner, so the nurse would not need to stick the patient again to obtain a blood glucose sample. She stated this technique was used for patient comfort.

During an interview on 4/30/19 at 11:32 a.m., staff member T stated staff were trained to start an IV and then obtain the blood sample for a point of care blood glucose test from the flash plug, while the IV and flash plug were still in the patient's vascular access site. The sample was not to be obtained from the IV flash plug once the steel needle and flash plug had been removed from the patient's venous access site.

During an interview on 5/1/19 at 9:56 a.m., staff member M stated the blood sample for a point of care blood glucose test should be obtained from "free-flowing whole blood, or a heparinized cap tube." She stated any sample that was not obtained in that manner had the potential to develop micro-clots and result in an invalid blood glucose reading. Staff member M stated there was no way to determine how quickly a blood sample might begin to clot after removing the IV flash plug from the patient's venous access site.

A review of the facility's policy and procedure titled, Glucometer-Xceed Pro, POC 107 V1.1, dated 5/2017, showed, "Specimen: Fresh free-flowing Whole Blood, if not fresh it must be heparinized and used within 30 minutes of collection... ."

Based on observation and interview, the facility failed to have a current diet manual readily available to medical and nursing personnel. This deficient practice had the potential to affect all patients eating in the hospital would be affected. Findings include:

During observation on 5/1/19 at 9:30 a.m. and 10:00 a.m., the inpatient rehabilitation and the medical/surgical floors did not have dietary manuals available. There was no information noted which directed staff on how to locate the diet manual, used by the facility.

During an interview and observation on 5/1/19 at 4:30 p.m., staff member B stated the updated diet manual was online. The online manual could not be located, at that time, by staff member B. The manual was not readily available to medical and nursing staff.

Based on observation, interview, and record review, the facility failed to ensure staff disposed of an IV needle immediately after use¹ for 1 (#13) of 30 sampled patients. Findings include:

During an observation on 4/30/19 at 9:36 a.m., staff member D used a Braun Introcan Safety-W IV Catheter to start patient #13's IV on his right arm. The nurse received flashback from the IV insertion and advanced the IV catheter, while removing the steel needle from the patient's arm. The steel needle had an automatic safety cap which covered the tip of the steel needle when it was removed from the patient's venous access site. Staff member D placed the capped steel IV needle into a basin and set it aside. She then applied an IV dressing over the IV site, and attached the IV tubing and started the patient's IV fluids. The nurse then brought the basin with the IV needle to the other side of the patient's bed, using gloved hands, removed the used steel needle from the basin. She held the IV steel needle in her left hand while she removed a blood sample from the needles flash plug, with a heparinized cap tube with her right hand. The nurse then applied the drop from the heparinized cap tube to the blood glucose test strip, and then disposed of the used needle in the sharps container.

During an interview on 4/30/19 at 10:00 a.m., staff member D stated she was trained to obtain the blood sample for a blood glucose test from the IV flash plug. She stated she obtained the sample from the flash plug reservoir, on the capped steel needle of the IV set. She stated used needles should be disposed of immediately after use, and the handling of used needles could increase exposure for a needle stick injury.

During an interview on 4/30/19 at 11:32 a.m., staff member T stated staff were trained to start an IV and then pull the blood sample for a point of care blood glucose test, from the flash plug, while the IV and flash plug were still in the patient's vascular access site. The sample was not to be obtained from the IV flash plug once the steel needle and flash plug had been removed from the patient's venous access site.

During an interview on 4/30/19 at 12:39 p.m., staff member T stated she discussed the process with the Braun Representative for the Introcan Safety-W IV Catheter, and their recommendation was to immediately dispose of the needle after it had been retracted from the patient's arm.

A review of the manufacture's guidelines for the Braun Introcan Safety-W IV Catheter, showed, "4... Dispose of needle immediately into sharps container... ."

References:

¹ Centers for Disease Control (CDC). (2015, February 2). Sharps Safety for Healthcare Settings. Retrieved from: https://www.cdc.gov/sharpssafety/