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Based on interview and review of the Patient Admission Packet, it was determined the facility failed to provide the State Agency name, address and phone number to patients. Failure to provide patients with the name, address and phone number of the State Agency did not inform or allow patients the opportunity to contact the State Agency to file a written or verbal complaint. The failed practice affected all in-patients on 01/03/12. Findings follow:

A. Review of the Patient Admission Packet revealed it did not contain the name, address and phone number of the State Agency whom patients could contact to file verbal or written complaints.
B. The above findings were verified by the Interim Chief Nursing Officer/Vice President of Quality Services on 01/06/12 at 1250.

Based on clinical record review and interview, it was determined 14 (#1-7, #13 and #15-20) of 21(#1-21) inpatient clinical records contained physician orders which were not dated and timed or signed within the facility's 48 hour time frame. Failure to date and time orders did not assure physician orders would be followed in the sequence intended by the ordering physician. Failure to authenticate physician orders within the 48 hour timeframe did not adhere to the Facility ' s policy and procedure. The failed practice affected 14 (#1-7, #13, and #15-20) of 21 (#1-21) inpatients on 01/03/12. Findings follow:

A. Review of Patient #1's physician orders revealed 19 were without a date and time and 2 orders without physician authentication within 48 hours.
B. Review of Patient #2's physician orders revealed 6 were without a date and time and 1 order without physician authentication within 48 hours.
C. Review of Patient #3's physician orders revealed 12 were without a date and time.
D. Review of Patient #4's physician orders revealed 3 were without a date and time and 1 order without physician authentication within 48 hours.
E. Review of Patient #5's physician orders revealed 9 were without a date and time and 1 order without physician authentication within 48 hours.
F. Review of Patient #6's physician orders revealed 15 were without a date and time and 3 orders without physician authentication within 48 hours.
G. Review of Patient #7's physician orders revealed 8 were without a date and time.
H. Review of Patient #13's physician orders revealed 6 were without date and time.
I. Review of Patient #15's physician orders revealed 2 were without a date and time and 1 order without physician authentication within 48 hours.
J. Review of Patient #16's physician orders revealed 28 were without a date and time and 3 orders without physician authentication within 48 hours.
K. Review of Patient #17's physician orders revealed 11 were without a date and time.
L. Review of Patient #18's physician orders revealed 5 were without a date and time.
M. Review of Patient #19's physician orders revealed were without a date and time and 2 orders without physician authentication within 48 hours.
N. Review of Patient #20's physician orders revealed 4 were without a date and time and 4 orders without physician authentication within 48 hours.
O. The above findings were verified by the Interim Director of Nursing in an interview at 1315 on 01/06/12.

Based on observation, interview, and review of pharmacy policy, the facility failed to ensure outdated medications were not available for patient use in 5 (Cardiac Care Unit, Nursery, Surgery, Gastrointestinal Lab, Pharmacy) of 10 (Cardiac Care Unit, Nursery, Surgery, Gastrointestinal Lab, Pharmacy, Post Anesthesia Care Unit, Pre-Operative Unit, Emergency Department, Obstetrical Unit, 3rd floor Medical/Surgical Unit) areas toured. The potential exists for patients to receive outdated medications. Findings follow:

A. A review of pharmacy policy and procedure entitled "Unusable and Outdated Drugs" dated 02/10/04 stated: "All discontinued patient drugs, outdated drugs, contaminated drugs, improperly stored drugs and containers with worn, illegible or missing labels shall be retuned to the Pharmacy Department for proper disposal."
B. A tour of 9 patient care areas was conducted on 01/04/12 between 0945 and 1515 revealed outdated medications were observed in 4 (Cardiac Care Unit, Nursery, Surgery and Gastrointestinal Unit) patient care areas as follows:
1) Cardiac Care Unit Crash Cart
a) Five Dextrose 5% 50 milliliters (ml) intravenous (IV) solution expired 08/11; and
b) Two Sodium Chloride 0.9% 100ml IV solutions expired 08/11.
2) Nursery Crash Cart-Two Sodium Bicarbonate 4.2% 10ml for injection expired 01/01/12.
3) Surgery Crash Cart
a) Four Sodium Bicarbonate 4.2% 10ml for injection expired 01/01/12; and
b) One Atropine Sulfate 1milligram (mg)/10ml for injection expired 01/01/12.
4) Gastrointestinal Lab Anesthesia Cart
a) Three Propofol 1% 50ml for injection-two expired 08/11 and one expired 09/11.
b) One Sodium Chloride 0.4% 100ml IV solution expired on 07/11.
c) One Heplock Flush syringe expired 10/11.
C. A tour of the Main Pharmacy was conducted on 01/05/12 from 1300 to 1515. Outdated medications were observed as follows:
1) Six Isolyte in 5% Dextrose 1000ml for IV expired 05/11;
2) Eight Lidocaine/Epinephrine 1:200000 50ml for injection expired 12/11;
3) One open bottle of Carafate Oral Suspension expired 10/11;
4) One Dexamethasone Ophthalmic Solution 0.1% 5ml expired on 10/11;
5) One Dextrose 30% 500 ml IV solution expired on 01/01/12;
6) Fifty Dextrose 5% 100ml IV solutions expired 08/11;
7) Two Lidocaine 2% 5ml for injection expired 01/01/12, 12/01/12;
8) Two Sodium Bicarbonate 4.2% 10ml for injection expired 11/01/11; and
9) Two boxes of Accu-Chek Test Strips expired on 10/31/11.
D. The following interviews were conducted to verify outdated medications:
1) Director of Pharmacy verified outdated medications in the main Pharmacy on 01/05/12 at 1315.
2) Director of Critical Care Unit (CCU) verified outdated medications in CCU on 01/04/12 at 1038.
3) Director of Labor & Delivery and Nursery verified outdated medications in Nursery on 01/04/12 at 1125.
4) Interim Director of Nursing verified outdated medications in Surgery on 01/04/12 at 1430.
5) Director of Surgical Services verified outdated medications in Gastrointestinal Lab on 01/04/12 at 1513.

Based on observation, interview, and review of the label on Rocuronium Bromide, the facility failed to ensure expiration dates were assigned to the labels put on the medication stored at room temperature not to exceed sixty days, according to manufacturer guidelines. The practice was observed in two (Operating Room #6, Operating Room #5) of two Operating Rooms toured. The potential existed for Rocuronium Bromide stored at room temperature to be administered beyond a 60 day expiation date as required by manufacturer and had the potential to affect all surgical patients who received Rocuronium Bromide. Findings follow:

A. The manufacturer label on Rocuronium Bromide was reviewed on 01/04/12 at 1400. The label reflected once Rocuronium Bromide was removed from refrigeration, the unopened vial of medication could be stored at room temperature for 60 days and the opened vial for 30 days.
B. A tour of Operating Rooms #6 and #5 was conducted on 01/04/2012 between 1400 and 1430. It was observed labels on Rocuronium Bromide stored at room temperature reflected expiration dates that exceeded 60 days once removed from refrigeration. The expiration dates were assigned by Pharmacy Services. Examples follow:
1) Operating Room #6 Anesthesia Cart-One Rocuronium Bromide 5 milliliter (ml) vial was labeled with an expiration of 03/14/12 allowing the medication to be stored for 70 days (date surveyed to expiration date) at room temperature.
2) Operating Room #6 Automated Medication Cabinet-Three Rocuronium Bromide 5 ml vials were labeled with an expiration of 03/15/12 or 03/16/12 allowing the medication to be stored for 71 days and 72 days (from date of survey to expiration date, respectively) at room temperature.
3) Operating Room #5 Anesthesia Cart-Three Rocuronium Bromide 5 ml vials were labeled with an expiration of 03/16/12, 03/15/12 allowing the medication to be stored for 72 days and 71 days (from date of survey to expiration date, respectively) at room temperature.
4) Operating Room #5 Automated Medication Cabinet-Three Rocuronium Bromide 5 ml vials were labeled with an expiration of 03/13/12, 03/16/12 allowing the medication to be stored for 69 days and 72 days (from date of survey to expiration date, respectively) at room temperature.
C. The following interviews were conducted to verify mislabeled medications:
1) Director of Surgical Services verified mislabeled medications in Operating Room #6 on 01/04/12 at 1400; and
2) Director of Surgical Services verified mislabeled medications in Operating Room #5 on 01/04/12 at 1430.

Based on credential review and interview, it was determined the designated Foodservice Director was not qualified in that there was no evidence the individual had formal education regarding all facets of food service to handle the complexity of food service operation . The failed practice had the potential to affect all patients receiving food from the department. Findings follow:

A. During interview of the Registered Dietitian on 01/05/12 at 1310, she was questioned on who was in charge of the Food Service Department. She stated, "The Chef" was the Food Service Director and she reported to him.
B. Review of the Foodservice Director's personnel file it was determined there was no evidence the director had formal education regarding all facets of food service to handle the complexity of food service operation.
C. Interview with the Registered Dietitian at 1245 on 01/05/12, she stated they were looking to hire a Certified Dietary Manager (considered a qualified individual), however, the person hired would supervise the department only on weekends.

Based on observation and interview it was determined the facility did not meet Life Safety Code requirements related to the protection of hazardous areas and the construction of smoke barrier walls. The failed practices had the potential to affect the health and safety of all patients, staff, and visitors due to the potential of the spread of fire and smoke that resulted from the unprotected areas. The facility had 54 inpatients and 6 observation patients on 01/04/12. See CMS-2567, K25 and K29.

Based on interview it was determined temperature and humidity was not monitored in seven of seven operating rooms and two of two endoscopy rooms. The failed practice had the potential to affect all patients admitted for surgical procedures due to the potential of bacterial growth in the environment due to excessive humidity, which could not be assured without consistent monitoring. The facility had 13 patients scheduled for surgery and 2 patients scheduled for endoscopy procedures on 01/04/12. The findings follow:

A. In an interview on 01/04/12 at 1350, a request was made to the Director of Surgical Services to review the temperature and humidity logs for the surgery department. He stated it was his understanding the Engineering Department monitored the temperature and humidity remotely, but his department had recently purchased gauges to monitor the levels within the surgery department. He verified the surgery department did not maintain any logs for review.
B. In an interview on 01/04/12 at 1545, the Director of Engineering/Construction stated his department was not currently monitoring temperature and humidity in the operating rooms and verified there was no documentation available for review.

Based on review of policies and procedures, observation and interview, the facility failed to assure a sanitary environment in that dust was present on equipment, the covering on chairs/stools was rippped or torn which did not allow for cleaning and disinfection, and clean and dirty equipment was separated. The failed practices did not assure the environment was free from contaminants or of infecting patients, staff and visitors with contamination and had the potential to affect all patients, staff and visitors to the facility. Findings follow:

A. During a tour of the Emergency Department (ED) on 01/04/12 at 0940, dust was under the gurney, on the crash cart base and on the Hill Rom tower in Main Trauma Room #2.
B. During a tour of the ED on 01/04/12 at 0950, dust was under the gurney in Trauma Room #1.
C. During a tour of the ED on 01/04/12 at 1000, dust was on a black plastic fan at the Nurses' station and there were four (4) vinyl chairs with tears and holes in the coverings which did not assure they could be cleaned or disinfected.
D. Findings were verified by the ED Manager at the time of the tour.
E. During a tour of the Critical Care Unit (CCU) on 01/04/12 at 1020, dust was on two (2) EKG (electrocardiogram) machines, on the "Computer on Wheels" (COW), on two (2) adult crash carts and on the pediatric crash cart. Findings were verified by the CCU Manager at the time of the tour.
F. During a tour of the Labor and Delivery (L&D) Unit on 01/04/12 at 1100, dust was on the bases of two (2) mobile vital signs monitors. Findings were verified by the L&D Manager at the time of the tour.
G. During a tour of the Medical Unit on 01/04/12 at 1130, dust was on the bases of two (2) COWs. Findings were verified by the Interim Director of Nursing at the time of the tour.
H. During a tour of Operating Room (OR) #6 on 01/04/12 at 1355, two (2) uncovered (clean) anesthesia circuits were hanging on the back of the Anesthesia machine. The Director of Surgical Services verified the circuits hang there during procedures (dirty) and then one was used for the following procedure which does not assure they remain clean following a surgical procedure or during room cleaning/turnover procedures.
I. During a tour of the OR Supply Room on 01/04/12 at 1410, multiple tears were in the covering of a reusable gel filled patient pad which did not assure it could be cleaned or disinfected. Findings were verified with the Interim Director of Nursing at the time of the tour.
J. During a tour of OR #5 on 01/04/12 at 1420, two (2) uncovered (clean) anesthesia circuits were hanging on the back of the Anesthesia machine to be used following a surgical procedure (dirty). Findings were verified with the Director of Surgical Services at the time of the tour.
K. During a tour of the Post Anesthesia Care Unit (PACU) on 01/04/12 at 1440, dust was on the shelf above Bed #1 and Bed #2. Findings were verified with the Director of Surgical Services at the time of the tour.
L. During a tour of the GI (Gastroenterology) Unit on 01/04/12 at 1500, eleven (11) endoscopes were hanging from a rack on the wall with two (2) EGD (Esophagogastroduodenoscopy) endoscope tips touching the counter top, in the Scope Processing room. The room was utilized for decontaminating, cleaning and storing endoscopes (clean and dirty). There was no cabinet enclosure for storing the endoscopes. In the hallway outside the Scope Processing room were four (4) endoscopes hanging in the corner with three (3) touching the wall and one (1) touching the floor. There was no cabinet enclosure for storing the endoscopes. Findings were verified with the Director of Surgical Services at the time of the tour.
M. During a tour of GI Room #1 on 01/04/12 at 1515, there were tears in a rolling stool's cover which did not allow for cleaning or disinfecting. Findings were verified with the Director of Surgical Services at the time of the tour.
N. During a tour of GI Room #1 on 01/04/12 at 1520, dust was on the prep table/cart. Findings were verified with the Interim Director of Nursing at the time of the tour.
O. During a tour of the GI Unit, on 01/04/12 at 1530, thirty (30) HP Fast Controls (clean) were in the bottom right drawer of the staff's food refrigerator (dirty). Findings were verified with the Director of Surgical Services at the time of the tour.
P. Review of Policy, "Separation of Clean and Dirty" stated, "Clean supplies will be stored in a separate location from dirty supplies". Findings were verified by the Interim Director of Nursing on 01/06/12 at 1345.
Q. Review of Policy, "Infection Control/Maintenance of Environment and Equipment" stated, "keeping clean and dirty items separate" and that surgical services nurses would, "monitor infection control and maintenance of environment and equipment". Findings were verified by the Interim Director of Nursing on 01/06/12 at 1345.

Based on review of clinical records and interview, it was determined that five (#2, #5, #7, #16 and #17) of six (#2, #5, #7, #9, #16 and #17) operative reports did not contain the date and time of surgery. Failure to record date and time of surgery on the operative report did not allow the clinical record and the operative report to be complete. The failed practice affected five (#2, #5, #7, #16 and #17) of six (#2, #5, #7, #9, #16 and #17) patients on 01/03/12. Findings follow:

A. Review of clinical records for six (#2, #5, #7, #9, #16 and #17) patients undergoing surgical procedures revealed two (#16 and #17) operative reports did not contain the date and time of the surgical procedure. Findings verified by the Interim Director of Nursing at 1110 on 01/06/12.
B. Review of clinical records for six (#2, #5, #7, #9, #16 and #17) patients undergoing surgical procedures revealed three (#2, #5 and #7) operative reports did not contain the time of the surgical procedure. Findings verified by the Interim Chief Nursing Officer/Vice President of Quality Services at 1250 on 01/06/12.

Based on review of policies and procedures and interview, the facility failed to assure respiratory therapy policies and procedures were approved by the Medical Staff and did not have a policy or protocol for posting signs when oxygen was in use. The failed practice did not assure policies and procedures were current and/or appropriate for patient care or that they were reviewed and approved for needed revisions and did not assure safety precautions were undertaken when oxygen was in use. The failed practices had the potential to affect all patients requiring respiratory therapy in the facility. Findings follow:

A. Review of the Respiratory Therapy Policies and Procedures Manual revealed it did not have evidence of the Medical Staff's review and/or approval.
B. Review of the Respiratory Therapy Policies and Procedures Manual revealed it did not have a policy addressing posting of signs when oxygen was in use.
C. On 01/06/12 at 1350, the Director of Respiratory Therapy stated that the facility had "Oxygen in Use" signs but that they were not routinely utilized.
D. During an interview with the Director of Respiratory Therapy on 1/06/12 at 1350, the findings were verified.