HospitalInspections.org

Based on observation, interview and policy search, the facility failed to ensure that a) expired, mislabeled, or otherwise unusable medications were identified, removed from service, and unavailable for patient-use, and that b) opened medications were labeled with date and time opened, date of expiration and initialled by the person who opened them ("not dated").

On 06-15-2015 at 10:15 a tour facility with employee #16 (Administrator), findings in the medication room and nurses station included:
1) one (1) bottle nitro-stat (sub-lingual tablet for chest pain) open, "not dated"
2) one (1) Fludrocortisone 0.1mg (expired 11/2014)
3) one (1) baclofen 10mg oral medication (expired 1/2015)
4) six (6) clonidine 0.2mg (expired11/2014)
5) eight (8) hydrocortisone suppository 25mg (expired 2/2015)
6) one (1) miacalcin 200 I.U. open, "not dated"
7) two (2) Gripper IV starter kits, expired 3/2014, 8/2013)
8) one (1) provent arterial blood sampling kit (expired 5/2013)
Items one through six confirmed by employee #16 (Administrator) and employee #12 (pharmacist), items #7 and #8 found in crash cart by nurse station by second surveyor and confirmed by employee #15 (DON).
Policy search revealed a policy entitled, "Floor Checks/Inspections" which documented in part " ...Unannounced monthly floor visits shall be made of each unit in the hospital to ascertain that storage, stocking, refrigeration, count and other factors on checklist are in order ... " the checklist includes under " ...Omnicell 1. Expiration audit complete and expired drugs removed ... " answer options are: Yes, No or N/A

Based on observation, review of policy and procedures and interview, the facility failed to ensure that infection control measures were implemented to prevent the risk of transmission of microorganisms in one (1) of two (2) patient rooms observed.


Findings include:

Observation on 6/16/15, at 1200 pm: employee #18 was observed entering patient #6 room, with a food tray, without donning a gown or gloves. Contact precautions signage was observed on patient #6 door.

Review of policy #2.0, titled " Infection Control; Subject: Isolation Precautions " , states in part " ...Use contact precautions, Gown and gloves are indicated ... " .

Interview with employee #19 on 6/16/15, at 1200 pm, confirmed the Infection Control policy. Employee #19 immediately reported findings to the Director of Nurses.

Based on medical record review, interview, and policy search the facility failed to provide signed informed consents for treatment for two (2) of twenty (20) inpatients whose medical records were reviewed.

Findings include:

Review of Medical record for patient #6 at 11:30 am on 6/16/15 with RN employee #19. This open record had an informed consent in the file which was not signed by the patient or anyone else except the admitting employee. No note was made on the consent as to why the patient did not sign the consent to treatment. Closed medical record review of patient #14 at 10:30 am on 6/18/15 with RN employee #19 failed to find an informed consent to treatment.

Interview with employee #19 at the above times confirmed that the informed consents were not signed and on file in the medical records.

Policy review of #101.8 entitled "Informed Consent", under section V letter D states in part "Hospital staff generally will provide information on simple and routine/common treatments and procedures which shall be included in hospital admission consent process by the pre-admissions nurse or admitting officer/registration officer..."

Based on medical record review, interview, and policy search the facility failed to provide one (1) patient with the first message from Medicare and one (1) patient with the second message from medicare. [The first message informs patients close to admission how to appeal an early discharge from the facility and the second such message is given again with enough time before anticipated discharge to appeal the discharge]. Two (2) of twenty (20) patients, the records of whom were reviewed, were potentially affected.

Findings include:

On 6/17/15 at 3:00 PM patient record #17 was reviewed and found to be missing the second message from Medicare before discharge. On 6/18/15 at 10:30 am patient record #15 was reviewed and found to not have the first important message for Medicare on the discharged patient's chart.

Interview with employee #19 on 6/17/15 at 3:00 PM and again on 6/18/15 at 10:30 am, the RN assisting in medical record review confirmed that the above messages could not be found in either record.

At 12:00 PM on 6/18/15 the Director of Nursing was asked for a policy about the important message from Medicare.

Policy #102.33 was produced and reviewed. This policy addressed advanced notification of Medicare not paying for certain items: CMS-R-131-G and -L. However, the policy did not mention CMS-R-193 which actually informs the patient about the procedure for appeal to not be discharged from the facility.