HospitalInspections.org

1. Based on reviews of the medical record and staff interviews the hospital failed to re-assess and provide interventions based on the needs of the patient for the entire admission through discharge.
The findings included:
a. Reviews of the medical record conducted on 1/12/2017 with staff member # 3 in the conference room revealed the patient had surgery on 5/13/2016 and had been transferred to the Intensive Care Unit (ICU) of PAM Specialty Hospital. According to the medical record the patient attempted to climb out of the bed several times. Upon transferring from the ICU no changes were made to address what had occurred and documentation varied on whether or not she was on fall precautions although notations for agitation and confusion are noted along with narcotics for pain control.
2. Interviews conducted with the complainant reveals he warned the Nursing staff for 6 days that his wife would attempt to crawl out of the bed and his request she be restrained for safety reasons or could she get a bed like those in the ICU was denied. The nursing staff did offer a bed alarm but according to the complainant the alarm did not work she, was placed on 1 on 1 monitoring for the night and the next day she had restraints on for the protection of the tracheotomy tube. The patient was moved closer to the nursing station but on July 5, 2016 the patient fell out of bed again and the alarm was not working then as well.
3. Following her own review of the record and the spouse's complaints Staff member # 3 acknowledged the nursing interventions were not responsive to new developments and she could not provide evidence of compliance with the requirements to keep the nursing care plan current via ongoing assessments of the patient.

Based on observation and interview, the hospital failed to meet the requirement for developing a system for controlling infections and communicable diseases because it did not ensure that contract dialysis staff used gloves for care of 1 patient of 1 patient observed on contact and droplet precautions and did not ensure masks and gloves were stocked in the contact isolation cabinet on 1 of 3 patient's doors.

During a tour of the hospital intensive care unit on 01/12/17 at 11:42 a.m. accompanied by the Chief Executive Officer, observation revealed that Patient #2 was on contact and droplet precautions. Contract Dialysis Nurse #1 was observed sitting next to the patient using a hand held device without wearing gloves.

In an interview on 01/12/17 at 11:42 a.m. in the intensive care unit, Chief Executive Officer confirmed the above findings and stated he would talk to the dialysis provider about the issue.

During a tour of the hospital on 01/12/17 at 12:30 p.m. accompanied by the Chief Executive Officer, observation revealed that the contact and precautions supply cabinet on the door of 1 of 3 rooms on Unit 2 did not contain masks and gloves.

In an interview on 01/12/17 at 12:30 p.m. on Unit 2, the Chief Executive Officer confirmed the above findings.