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Based on record review, interview, and review of the facility's "Medical Staff Bylaws and Rules and Regulations," the facility failed to ensure the medical records for 2 of 19 sampled patients (Patient (P) 9 and P13) contained the patients' History and Physical document.

Findings include:


1. Review of P9's electronic medical chart indicated the facility admitted the patient on 1/1/18 with a diagnosis of sickle cell (a group of blood cells that cause red blood cells to become misshapen and break down) and discharged the patient on 1/9/18. Further review of P9's medical record revealed it did not contain a History and Physical document.


2. Review of P13's electronic medical chart indicated the facility admitted the patient on 1/7/18 with diagnoses of heart failure and hypertension. Further review of P13's medical record revealed it did not contain a History and Physical document.


During an interview on 1/10/18 at 11:45 p.m., the Vice President of Performance Improvement (VPPI) stated the History and Physical for each patient should be in the electronic medical record no later than 24 hours after the patient's admittance to the hospital. The VPPI reviewed the documentation in the electronic medical record and in the paper-based medical record for both P9 and P13 and confirmed that neither source contained a History and Physical document for either patient.


Review of the facility's "Medical Staff Bylaws & Rules & Regulations" (approved July 2008), indicated under the section titled, "II. Medical Record" (page 7), the document specified:


"2. For all admissions, the attending physician shall, within the first twenty-four (24) hours from the time of Admission, either write or dictate a complete history and physical. For all patients admitted to the ICU (Intensive Care Unit) from the emergency room, the physician shall (a) write or dictate the history and physical, or (b) write on the progress note an adequate admission note with the essential and pertinent information needed for evaluation and treatment of the patients, within six (6) hours from the time of admission. For purposes of this paragraph the time of admission shall be the time that is documented on the Inpatient Admission Sheet. 3. For all admissions, whether emergency or routine the attending physician shall dictate or electronically complete history and physical within 24 hours."

Based on observation, interview, and policy review, the facility failed to ensure they provided and maintained an acceptable level of safety and well-being of patients, when the facility failed to follow manufacturer's directions for proper storage of laboratory controls and failed to ensure expired respiratory equipment was removed from storage cabinets. The deficient practice had the potential to affect all pediatric and respiratory care patients admitted to the hospital.


Findings include:


1. Observation on 1/8/18 at 12:15 p.m., during the initial tour of the Laboratory Department, revealed the chemistry refrigerator freezer contained six boxes of "Liquichek Pediatric Controls," used as a quality control serum to monitor the precision methods and techniques of laboratory practices. The outside freezer door revealed a temperature log form titled, "Refrigerator Temp Log, RLS CONTROL 90102 (a reagent used for laboratory tests), Freezer Temp Range -20C to -35C" for the month of January 2018. The temperature log was specific to the manufacturer's directions for the safe storage of the RLS CONTROL reagents and between -15 degrees C (Celsius) to -25 degrees C. Information on the "Liquichek Pediatric Control" manufactures direction for safe storage specified that the freezer temperature was to be maintained at -20 degrees C (Celsius) to -70 degrees C. The freezer temperature log revealed laboratory staff documented the freezer temperature for January 2018, from 1/1/18 through 1/7/18 as follows:


a. On 1/1/18: -18 degrees C;


b. On 1/2/18: -18 degrees C;


c. On 1/3/18: -18 degrees C;


d. On 1/4/18: -16 degrees C;


e. On 1/5/18: -18 degrees C;


f. On 1/6/18: -18 degrees C; and


g. On 1/7/18: -16 degrees C.


For the first 7 days in January 2018, the laboratory department staff failed to maintain the "Liquichek Pediatric Controls" freezer temperature inside the department's chemistry freezer within the manufacturer's directions for safe storage between -20 degrees C to -70 degrees C.


During an interview on 1/8/18 at 12:30 a.m., the Laboratory Director confirmed that the freezer temperature log indicated the manufacturer's directions for the RSL reagents to be maintained as follows:

-15 degrees C to 25-degrees C. The Laboratory Director verified staff failed to follow the "Liquichek Pediatric Control" manufacturer's directions for safe storage between -20 degrees C to -70 degrees C.


Review of the "Liquichek Pediatric Control, Level 1 and 2, Expiration 01/31/2019, Lot 21660" insert with the manufacturer's directions provided the following information:


". . . This product will be stable until the expiration date when stored unopened at -20 degrees to -70 degrees C."


2. Observation on 1/8/18 at 12:40 p.m., during the initial tour of the Respiratory Department revealed the "Shiley Tracheostomy Tubes" for pediatric patients were stored in the department's cabinet area. Further observation revealed the following expiration dates of the tracheostomy tubes: one box expired on 11/16, one box expired on 05/2017, and 8 boxes expired on 8/2017.


During an interview on 1/8/18 at 12:50 p.m., Respiratory Staff 3 verified he/she checks for expired supplies and equipment on a monthly routine. Staff 3 shared he/she overlooked the cabinet and were unaware the tracheostomy tubes had expired.


Review of the Respiratory Department's policy and procedure titled, "Equipment Processing," signed 6/9/06, provided the following information:


". . . Storage of Equipment . . . E. On a daily basis, the shelf life and expiration date for sterile items are checked and the stock is rotated by respiratory care personnel . . . F. . . .items are checked for expiration date . . ."

Based on observation and interview, the facility failed to ensure the dietary staff appropriately dried kitchen utensils, in that dietary staff stacked wet pots and serving containers directly on top of each other, which prevented thorough air-drying of the items. This deficient practice had the potential to affect all the 24 patients in the facility that received meals from the dietary department.


Findings include:


Observation of the dietary department on 1/8/18 at 12:30 p.m. revealed 2 serving containers on the drying rack, stacked one inside the other. The Dietary Manager separated the containers, which were wet on the inside surface of each container. Continued observations revealed 2 additional serving containers and 2 pots that were also stacked one inside the other and when separated were wet on inside surface of each container.


During an interview on 1/8/18 at 12:30 p.m., the Dietary Manager and the Infection Control Coordinator both were asked if stacking the utensils inside one another was an appropriate way to dry the utensils. Both stated that stacking wet serving containers and pots one inside the other was an infection control issue and the utensils should be allowed to dry before stacking one inside the other.