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Referenced code: Title 42 CFR 485.623(c)

Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in one (above the fire-rated doors near the Courtyard labeled "Healing Garden") of six areas observed by protecting penetrations in the barrier with a system or material capable of limiting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility with the Maintenance Supervisor on 03/28/2017 at 1320, two penetrations in the fire-rated barrier above the fire-rated doors near the Courtyard were not sealed with a system or material capable of limiting the transfer of smoke from one side of the barrier to the other.
B. During the tour, the Maintenance Supervisor verified the penetrations were not sealed with a material capable of limiting the transfer of smoke from one side of the barriers to the other.
C. See K300.


Based on interview with the Maintenance Supervisor, there was no evidence available for review that maintenance and testing had been performed on the fire alarm system for 12 of 12 months requested. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured the alarm system would function as required during a fire emergency. Findings follow:

A. During an interview with the Maintenance Supervisor on 03/29/2017 at 0900, documentation a fire alarm inspection and testing had been performed for the previous 12 months requested. Following an investigation by the Maintenance Supervisor it was revealed no documentation was available that maintenance and testing had been performed on the fire alarm system by the monitoring company.
B. See K345.


Based on review of the Fire Drill log and interview, there was no evidence available for review that 4 (second quarter: first and second shifts, third quarter: first and second shifts) of 8 required fire drills from the second quarter of 2016 through the first quarter of 2017 had been performed. Failure to perform the required fire drills had the potential to affect the health and safety of all patients, visitors, and staff because the facility could not assure that the facility staff would be prepared to respond appropriately during a fire emergency. Findings follow:

A. Review of the Fire Drill log on 03/28/2017 at 0930 revealed no evidence fire drills had been performed for the first and second shifts of the second and third quarters of 2016.
B. During an interview on 03/29/2017 at 1000, the Maintenance Supervisor verified there was no documentation available which demonstrated all of the required fire drills had been performed.
C. See K712.

Referenced code: Title 42 CFR 485.623(d)

Based on observation and interview, it was observed the electrical panels in two (waiting area near patient rooms and Dietary storage) of seven areas observed did not have a minimum of 36 inches (three feet) working space in front of the panels because of equipment stored in those areas. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency. Findings follow:

A. While touring the facility on 03/28/2017 at 1400, chairs were observed in front of the electrical panels in the waiting area near the patient sleeping rooms.
B. While touring the facility on 03/28/2017 at 1415, a desk was observed in front of the electrical panels in the dietary storage area.
C. During the tour, it was verified by the Maintenance Supervisor the electrical panels did not have the minimum 36 inches of working space in front of them.
D. See K911.

Based on observation and interview, the facility failed to ensure out of date medications were not available for patient use on two of two (Pediatric Crash Cart, Adult Crash Cart) Crash Carts in the Emergency Department (ED). The likelihood existed for patients in the ED to receive out of date medications from the two Crash Carts. Findings follow:

A. A tour of the ED was conducted on 03/27/17 at 1355. Outdated medications were observed on the Pediatric Crash Cart and the Adult Crash Cart as follows:
1) Pediatric Crash Cart
a) Two prefilled syringes of Pediatric 8.4% Sodium Bicarbonate expired 03/01/17; and
b) One prefilled syringe of Lidocaine 50 milligrams (mg)/5 milliliters (ml) expired 03/01/17.
2) Adult Crash Cart
a) Two prefilled syringes of Pediatric 8.4% Sodium Bicarbonate expired 03/01/17;
b) Six prefilled syringes of Lidocaine 50 mg/5 ml expired 03/01/17; and
c) One prefilled syringe of Dextrose 25 grams (gm)/50 ml expired 03/01/17.
B. The Director of Nurses (DON) was interviewed on 03/27/17 at 1410. The DON verified through interview the two prefilled syringes of Pediatric 8.4% Sodium Bicarbonate and one prefilled syringe of Lidocaine 50 mg/5 ml on the Pediatric Crash Cart were expired. The DON verified in the same interview the two prefilled syringes of Pediatric 8.4% Sodium Bicarbonate, six prefilled syringes of Lidocaine 50 mg/5 ml, and one prefilled syringe of Dextrose 25 gm/50 ml on the Adult Crash Cart were expired.


Based on review of Patient Care Area Pharmacy Inspection Reports and interview, the facility failed to ensure three (Scope Procedure Room, Computerized Axial Tomography (CT) Room, and Radiology) of six (Scope Procedure Room, CT Room, Radiology, Medical/Surgical Nursing Unit, Emergency Department (ED), Swing Bed Nursing Unit) areas maintaining medications were inspected monthly for the time period of 01/25/16-02/22/17 as required by standard of practice of Pharmaceutical Services. The likelihood existed for medications to be outdated in the three areas not inspected and administered to patients. Findings follow:

A. Patient Care Area Pharmacy Inspection Reports were reviewed on 03/28/17 at 1230 for the time period 01/25/16-02/22/17. There was no evidence the following medication areas had been inspected monthly:
1) Scope Procedure Room;
2) CT Room; and
3) Radiology.
B. An interview was conducted with the Director of Pharmacy (DOP) on 03/29/17 at 0900. Through interview it was revealed it was a standard of practice for inspections to be done of all medication areas monthly. Through the same interview, the DOP verified there was no evidence monthly inspections had been conducted for the Scope Procedure Room, CT Room and Radiology for the time period 01/25/16-01/22/17.


Based on the review of the Patient Emergency Supply log and interview, the facility failed to ensure nurses documented the complete names of patients for 9 of 18 entries between 01/24/17-02/13/17 as required by Pharmacy standard of practice. The likelihood existed for the Pharmacist to be unable to readily verify patients in which medications were removed from the Pharmacy and administered after the department closed. Findings follow:

A. The Patient Emergency Supply log maintained in the Pharmacy when medications were obtained when a Pharmacist was not on duty for the time period 01/24/17--2/13/17 was reviewed on 03/28/17 at 1455. It was revealed 9 of 18 entries lacked complete names of patients.
B. An interview was conducted with the DOP on 03/29/17 at 0930. Through interview, the DOP revealed it was Pharmacy standard of practice for the complete names of patients to be documented on the log when medications were removed from the Pharmacy after the department closed. It was also verified in the same interview 9 of 18 entries on the log lacked a complete names.


Based on the review of Change of Shift Discrepancy Reports and interview, the facility failed to ensure an on-coming and off-going nurse verified through documentation at the change of shifts whether there were any discrepancies of scheduled medications on Omnicells on two (Emergency Department (ED), Medical/Surgical Unit) of two (ED, Medical/Surgical Unit) nursing units as required by Pharmacy standard of practice. The likelihood existed for scheduled medication discrepancies to go undetected at the change of shifts. Findings follow:

A. On 03/27/17 between 1335 and 1440 a tour was conducted of the facility in which two Omnicells were observed located in the ED and the Medical/Surgical Unit. There was no Change of Shift Discrepancy Reports available to review which would indicate an oncoming and off-going nurse had verified scheduled medication discrepancies at the change of shifts.
B. On 03/29/17 at 0930, the DOP was interviewed. Through interview it was revealed it was a Pharmacy standard of practice for the oncoming and off-going nurse to verify through documentation whether there were discrepancies of scheduled medications at the change of shifts on the Omnicells. It was verified through the same interview there was no evidence in the ED, Medical/Surgical Unit, or Pharmacy that Change of Shift Discrepancy Reports had been conducted.


Based on review of Pharmacy Policy #3.5.8, review of Omnicell Inventory Forms and interview, the facility failed to ensure a scheduled drug inventory (count of all scheduled medications) was conducted biweekly by nursing staff on Omnicells located on two (Emergency Department (ED), Medical Surgical Unit) of two (ED, Medical Surgical Unit) nursing units as required by policy for the time period 02/01/17-02/26/17. The likelihood existed for scheduled medication discrepancies to exist on the Omnicells. Findings follow:

A. Pharmacy Policy #3.5.8 was reviewed on 03/28/17 at 0945. The policy reflected scheduled medication inventories would be conducted on the Omnicells biweekly on Wednesdays and Sundays.
B. A review of the Omnicell Inventory Forms for the time period 02/01/17-02/26/17 for the two Omnicells was conducted on 03/29/17 at 1000. It was revealed six of eight required inventories for the Omnicell in the ED had not been conducted, and two of eight inventories for the Omnicell on the Medical/Surgical Unit had not been conducted.
C. An interview was conducted with the DOP on 03/29/17 at 1015. It was verified through interview six scheduled medication inventories had not been conducted for the Omnicell located in the ED and two inventories had not been conducted for Omnicell located on the Medical/Surgical Unit for the time period 02/01/17-02/26/17 as required by policy.

Based on review of manufacturer's instructions for use, review of Metricide OPA Plus Solution logs, review of Policy and Procedure Manuals and interview, it was determined the facility failed to prevent and control infections in that the staff did not follow manufacturer's instructions to monitor the temperature of Metricide OPA Plus Solution with each use in two of two (Endoscopy and Respiratory) areas performing high level disinfection of semi-critical equipment. Failure to follow manufacturer's instructions did not assure patients were protected from sources of infection and had the likelihood to affect all patients receiving procedures utilizing semi-critical equipment requiring high level disinfection. Findings follow:

A. Review of the Endoscopy Metricide OPA Plus Solution log on 03/27/17 at 1540 revealed there was no evidence of the temperature recorded of the Metricide OPA Plus Solution for the dates of 04/21/15-03/07/17.
B. Review of Endoscopy Policy and Procedure: SUBJECT: SOAK DISINFECTION SYSTEM - GLUTARALDEHYDE - DEPARTMENT: GASTROINTESTINAL (GI) LABORATORY ON 03/29/17 at 0934 revealed "Follow manufacturer's instructions for exposure time."
C. Review of Respiratory Metricide OPA Plus Solution log on 03/29/17 at 0903 revealed there was no evidence of the temperature recorded of the Metricide OPA Plus Solution for the dates of 07/16/15-03/28/17.
D. Review of Respiratory Policy and Procedure: DECONTAMINATION PROCEDURES:
"A. Chemical
1. Metricide OPA Plus - A high level disinfectant will be used to clean all equipment that has to be submerged for Chemical decontamination according to manufactory directions..."
E. Review of Metricide OPA Plus Solution instructions for use on 03/28/17 at 1015 revealed "Manual Processing: High Level Disinfectant at a minimum of 20 degrees Celsius (68 degrees Fahrenheit). Metricide OPA Plus Solution is a high level disinfectant when used or reused, according to the Directions for Use, at or above its Minimum Recommended Concentration (MRC) as determined by Metricide OPA Plus Solution Test Strips, with an immersion time of at least 12 minutes for a reuse period not to exceed 30 days."
F. Findings in A verified with Registered Nurse (RN) #2 during interview on 03/28/17 at 1000.
G. Findings in C verified with the Respiratory Therapy Department Leader during interview on 03/29/17 at 0905.


Based on review of manufacturer's instructions for use, review of Metricide OPA Plus Solution logs and interview, it was determined the facility failed to prevent and control infections in that the staff did not follow manufacturer's instructions to perform testing of positive and negative controls on two of two (Endoscopy and Respiratory) bottles of Metricide OPA Plus Solution Test Strips in use. Failure to follow manufacturer's instructions did not assure patients were protected from infection and had the likelihood to affect all patients receiving procedures utilizing semi-critical equipment requiring high level disinfection. Findings follow:

A. Review of Endoscopy Metricide OPA Plus Solution log on 03/27/17 at 1540 revealed there was no evidence of positive and negative control testing of Metricide OPA Plus Solution Test Strips for the dates of 04/21/15-03/07/17.
B. Review of Respiratory Metricide OPA Plus Solution log on 03/29/17 at 0903 revealed there was no evidence of positive and negative control testing of Metricide OPA Plus Solution Test Strips for the dates of 07/16/15-03/28/17.
C. Review of Metricide OPA Plus Solution Test Strips instructions for use on 03/28/17 at 1015 revealed "Quality Control Test for Test Strips: Testing of positive and negative controls must be performed on each newly opened bottle of Metricide OPA Plus Solution Test Strips."
D. Findings in A verified with RN #2 during interview on 03/28/17 at 1000.
E. Findings in B verified with the Respiratory Therapy Department Leader during interview on 03/29/17 at 0905.

Based on observation, review of policy and procedure and interview, it was determined the facility failed to prevent and control infections in that the facility had no policy to provide instruction for the storage interval for two of two (Esophagogastroduodenoscope and Colonoscope) reprocessed endoscopes. Failure to establish a policy and procedure for removing and reprocessing an endoscope once the storage time had been exceeded did not assure endoscopes remained free from contamination and sources of infection and had the likelihood to affect all patients admitted to the facility for endoscopy procedures. Findings follow:

A. Observation of one of one Endoscope Storage Cabinet in the Endoscope Procedure Room on 03/27/17 at 1340 revealed one Esophagogastroduodenoscope (EGD) and one Colonoscope. The endoscope cabinet was ventilated and the EGD and Colonoscope were hanging freely. There was no indication of a processed date or reprocessing requirement date on either endoscope.
B. Review of Policy and Procedure Manuals on 03/27/17 at 1515 revealed no evidence of a policy and procedure providing instructions for the storage interval for reprocessed endoscopes.
C. An interview was conducted with the Director of Nursing, RN #1, RN #2 and the Infection Control Nurse on 03/28/17 at 1000. The Director of Nursing and RN #2 verified there was no indication of when the scopes had been processed visible on the endoscopes or in the storage cabinet. The Director of Nursing and the Infection Control Nurse verified the facility did not have a policy for the storage interval for reprocessed endoscopes and did not follow any nationally recognized professional guidelines for storage interval for reprocessed endoscopes.

Based on clinical record review and interview, it was determined the facility failed to ensure the clinical records for 2 (#17 and #18) of 7 (#14-#20) inpatients had a history and physical within 48 hours of admission per facility policy. The failed practice did not ensure the physician was knowledgeable of the patient's medical history and current medical status, and created the potential to affect any patient admitted to the facility. Findings follow.

A. Review of policy titled "Medical Record Guideline for Physicians" stated "A comprehensive history and physical (H&P) examination shall be completed within 48 hours of admission to inpatient services or prior to surgery by the appropriate practitioner privileged to perform H&Ps."
B. Review of clinical records revealed the following:
1) Patient #17 was admitted on 03/24/17. No H&P was in the clinical record as of the time of record review on 03/29/17 at 1356
2) Patient #18 was admitted on 03/23/17. No H&P was in the clinical record as of the time of record review on 03/29/17 at 1343.
C. The findings were confirmed by the Director of Swing-Bed at the time of clinical record review.


Based on clinical record review and interview, it was determined the facility failed to ensure the clinical records for one of one (#1) Swing-Bed patient had a history and physical within 48 hours of admission as per facility policy. The failed practice did not ensure the physician was knowledgeable of the Patient's medical history and current medical status, and created the potential to affect any patient admitted to the facility. Findings follow.

A. Review of policy titled "Medical Record Guideline for Physicians" stated, "A comprehensive history and physical (H&P) examination shall be completed within 48 hours of admission to inpatient services or prior to surgery by the appropriate practitioner privileged to perform H&Ps."
B. Review of the clinical record of Swing-Bed Patient #1 revealed the patient was admitted to Swing-Bed on 03/27/17 at 1224. There was no H&P on the clinical record as of the time of clinical record review on 03/29/17 at 1247.
C. The findings were confirmed by the Director of Swing-Bed at the time of clinical record review.


36533

Based on clinical record review and interview, it was determined the facility failed to assure Operative Reports included the time of surgery in 6 of 6 (#8-#13) surgical records. Failure to assure the time a surgical procedure took place did not establish a time-line of surgical events in the course of a patient's admission to the facility. The failed practice was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Clinical record review was conducted on 03/29/17 from 1245 - 1430 and revealed the following:
1) Operative Report dated 03/21/17 for Patient #8 revealed no evidence of the time of the surgical procedure.
2) Operative Report dated 03/07/17 for Patient #9 revealed no evidence of the time of the surgical procedure.
3) Operative Report dated 03/07/17 for Patient #10 revealed no evidence of the time of the surgical procedure.
4) Operative Report dated 02/21/17 for Patient #11 revealed no evidence of the time of the surgical procedure.
5) Operative Report dated 02/07/17 for Patient #12 revealed no evidence of the time of the surgical procedure.
6) Operative Report dated 01/19/17 for Patient #13 revealed no evidence of the time of the surgical procedure.
B. Findings in A were verified at the time of clinical record review by Registered Nurse (RN) #1.

Based on review of clinical records, review of Medical Record Guidelines for Physicians and interview, it was determined the facility failed to assure comprehensive history and physical (H&P) examinations were conducted within 30 days prior to surgery for 4 (#8-#10 and #12) of 6 (#8-#13) patients undergoing a surgical procedure. Failure to perform a comprehensive history and physical examination did not assure the patients overall physical condition had been assessed to determine the patient's readiness for the planned surgery. The failed practice had the likelihood to affect all patients admitted to the facility for surgery. Findings follow:

A. Clinical record review was conducted on 03/29/17 from 1245-1430 and revealed the following:
1) Review of the Operative Report dated 03/21/17 for Patient #8 revealed a history and physical examination dated 02/07/17 which was greater than 30 days prior to surgery and did not assure the exam findings were current.
2) Review the Operative Report dated 03/07/17 for Patient #9 revealed no evidence of a history and physical examination.
3) Review of the Operative Report dated 03/07/17 for Patient #10 revealed a history and physical examination dated 01/17/17 which was greater than 30 days prior to surgery and did not assure the exam findings were current.
4) Review of the Operative Report dated 02/07/17 for Patient #12 revealed a history and physical examination dated 01/03/17 which was greater than 30 days prior to surgery and did not assure the exam findings were current.
B. Review of Medical Record Guidelines for Physicians on 03/29/17 at 1403 revealed
"History and Physical Examinations: A comprehensive H&P examination shall be completed within 48 hours of admission to inpatient services or prior to surgery by the appropriate practitioner privileged to perform H&Ps."
"H&P examination may be completed ahead of time, though no more than 30 days prior to admission or re-admission, and only by the appropriate practitioner privileged to perform H&Ps."
C. Findings in A were verified at the time of clinical record review by Registered Nurse (RN) #1.

Based on Quality Assurance/Performance Improvement (QAPI) Plan review, Governing Board Meeting Minutes review, and interview, it was determined the facility failed to ensure the QAPI Plan was approved annually by the Governing Board from April 2016-March 2017. The failed practice did not ensure the Governing Board was aware of the quality indicators, and which items needed corrective action. Findings follow.

A. Review of the Hospital Wide Quality Assurance/Performance Improvement Plan stated "The Governing Board will review reports of findings, actions and results from performance improvement activities quarterly, and approve the plan annually, in order to assess the programs efficiency and effectiveness."
B. Review of Governing Board Meeting Minutes from April 2016-March 2017 revealed no evidence the QAPI Plan had been approved.
C. During an interview on 03/29/17 at 0840, the Administrative Assistant confirmed the QAPI Plan had not been approved in the past 12 months.

Based on review of Swing-Bed policies and procedures and interview, it was determined there were no policies and procedures addressing the patient's rights to work in the facility during their hospitalization. The failed practice did not assure patients with a need for therapeutic work rehabilitation were allowed to work or were allowed to refuse to work during their hospitalization and was likely to affect all patients needing work rehabilitation in the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing patients working or refusing to work while admitted to the facility.
B. During an interview on 03/29/17 at 0925, the Director of Swing Bed confirmed there was no policy regarding patient's right to work.

Based on review of Swing-Bed policies and procedures and interview, it was determined there were no policies and procedures addressing when married couples admitted to the facility could room together. Failure to assure policies allowing married couples to room together did not assure married couples' choices to room together were honored and was likely to affect all married couples admitted to the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing married couples rooming together while admitted to the facility.
B. During an interview on 03/29/17 at 0925, the Director of Swing Bed confirmed there was no policy regarding married couples.