HospitalInspections.org

Based on observation, interview and policy review, the hospital failed to ensure three patients (#1, #18, and #36) were provided with a call system that was in reach and appropriate for their special needs, and two of two emergency airway carts were checked daily.
These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 10/23/24, the hospital provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on call light appropriateness and availability. All remaining staff were educated prior to the start of their next shift.

Please refer to A-0144.

Based on observation, interview and policy review, the hospital failed to ensure three patients (#1, #18, and #36) were provided with a call system that was in reach and appropriate for their special needs, and two of two emergency airway carts were checked daily.
Findings included:

1. Although requested, the hospital failed to provide a policy that addressed the use of call lights for special needs.

Observation on 10/22/24 at 10:25 AM, showed Patient #1 with a mitten (restrictive mitt that hinders picking and tube pulling) restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) on her left hand and a standard call light within reach. Patient #1 was unable to use her right hand.

During an interview on 10/22/24 at 10:30 AM, Staff E, Nurse Manager, stated that she would expect a soft touch call light for a patient with mittens on.

Observation on 10/22/24 at 10:50 AM, showed Patient #18 was paralyzed with a ventilator (a machine that supports breathing) in place and a soft touch call light that laid on the ventilator machine, out of reach of the patient.

Observation on 10/22/24 at 2:45 PM, showed Patient #18 was paralyzed with a ventilator in place and a soft touch call light laid on the patients' abdomen, out of reach of the patient.

Observation on 10/23/24 at 9:45 AM showed Patient #36 was a left arm amputee (removal of an injured or diseased body part) on a ventilator and in a soft limb restraint on her right arm and the call light was on the floor out of reach of the patient.

During an interview on 10/23/24 at 9:43 AM, Staff B, Chief Nursing Officer (CNO), stated that she expected call lights be accessible and appropriate for the patients.

2. Review of the hospital's policy titled, "Emergency Equipment Checking Procedure," dated 10/01/23, directed staff to check the emergency airway cart every shift.

Review of the airway cart check lists showed the emergency airway cart on the acute nursing unit was checked on 08/28/24, 09/03/24, and 09/28/24. The emergency airway cart on the rehabilitation (the action of restoring someone to health or normal life through training and therapy) unit was checked on 08/01/24 and last checked on 08/26/24.

Observation on 10/21/24 at 1:20 PM, showed an emergency airway cart last checked 09/28/24 and was located on the acute nursing unit.

Observation on 10/22/24 at 2:15 PM, showed an emergency airway cart with no current check list.

During an interview on 10/21/24 at 1:20 PM, Staff I, Respiratory Therapist, stated that the emergency airway cart was check when it was opened.

During an interview on 10/22/24 at 2:00 PM, Staff Q, Respiratory Therapy Manager, stated that the emergency airway carts were checked every month.





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Based on observation, interview and policy review, the hospital failed to ensure proper medication administration for six patients (#1, #11, #15, #16, #17, and #18) of six patients observed whose medications were administered through a feeding tube.

Findings included:

Review of the hospital's policy titled, "Medication Administration: Feeding Tubes," dated 07/01/24, showed each medication should be placed in a sealed plastic sleeve and crushed one at a time. After each medication is given, the feeding tube should be flushed with 20 milliliters (ml) of water.

Observation on 10/22/24 at 10:25 AM, showed Staff O, Registered Nurse (RN), placed four medications in one plastic sleeve, crushed them and administered to Patient #1 through the feeding tube.

Observation on 10/22/24 at 9:50 AM, showed Staff M, RN, placed five medications in one plastic sleeve, crushed them and administered to Patient #11 through the feeding tube.

Observation on 10/22/24 at 9:10 AM, showed Staff N, RN, placed seven medications in one plastic sleeve, crushed them and administered to Patient #15 through the feeding tube.

Observation on 10/22/24 at 9:30 AM, showed Staff N, RN, placed five medications in one plastic sleeve, crushed them and administered to Patient #16 through the feeding tube.

Observation on 10/22/24 at 9:45 AM, showed Staff O, RN, placed seven medications in one plastic sleeve, crushed them and administered to Patient #17 through the feeding tube. She then crushed one pain medication and mixed it with a liquid antibiotic prior to administering through the feeding tube.

Observation on 10/22/24 at 10:50 AM, showed Staff O, RN, placed three medications in one plastic sleeve, crushed them and administered to Patient #18 through the feeding tube.

During an interview on 10/22/24 at 9:10 AM, Staff N, RN, stated that she flushed the feeding tube with 20 ml of water before and after she administered medications.

During an interview on 10/22/24 at 12:47 PM, Staff C, Pharmacy Director, stated that he would expect nursing staff to follow the medication administration policy.





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