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Based on observation and staff interview, the facility failed to properly post notification signs regarding the absence of a Medical Doctor (MD) or Doctor of Osteopathy (DO) in 1 of 1 emergency rooms. Findings include:

On 1/28/14, beginning at 7:15 a.m., the surveyor observed the facility entrances and the emergency department. The facility had placed a single notice, in size 12 font, on an 8 1/2 by 11 inch sheet of bright pink paper, on the emergency room wall. The notice was located 6 feet off the floor, next to the desk in the emergency room. The notice carried no heading addressing the purpose of the notice, or other information to draw attention to the notice. There were no signs posted outside of the emergency room or in other prominent locations within the facility.?

During an interview on 1/29/14 at 4:50 p.m., staff member A, the CEO, verified that the single sign had been posted to notify patients that a MD or DO was not available in the facility 24 hours a day, seven days a week, but the size and location was not adequate.


? Federal Regulations read as follows;
Individual notices are not required in the CAH's dedicated emergency department (DED) (as that term is defined in 42 CFR 489.24(b)), but the DED must post a notice conspicuously, in a place or places likely to be noticed by all individuals entering the dedicated emergency department. The posted notice must state that the CAH does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and must indicate how the CAH will meet the medical needs of any patient with an emergency medical condition, as defined in 42 CFR 489.24(b).

Based on observation and staff interview, the facility failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality in two (Medical floor and Emergency room) of two patient care areas of the hospital. Findings include:

On 1/28/14 at 7:15 a.m. the emergency room of the hospital was observed. The surveyor noted multiple expired patient care supply items available for use for patients presenting to the emergency room for care.
Those items included the following items;
-three Nellcor Easycap II end tidal CO2 detectors with the manufacturer's expiration date of 9/13.
-six Kendall 16 French Salem Sump tubes with the manufacturer's expiration date of 10/13.
-one package of Medtronic Quick Combo cardiac pacing electrodes with the manufacturer's expiration date of 10/28/2011.
-one Nellcor Emergency Cricothyrotomy Cath Set with the manufacturer's expiration date of 11/09.

The expired supply dates in the emergency room were verified by staff member A, the facility CEO, on 1/28/13 at 8:10 a.m.

Staff member B, the DON, stated on 1/28/14 at 3:00 p.m., that members of the nursing staff were responsible for checking for outdated supplies and medications. Staff member B was unable to locate or provide a copy of the facility policy addressing the review of supplies for outdates by the end of the survey on 1/29/14.

Patient care supplies on the Medical floor were reviewed on 1/29/14 at 9:30 a.m. The surveyor noted the following expired/unusable patient care supplies in open stock, and available for use;
- two boxes of 50/box Kendall Xeroform Petrolatum dressings with the manufacturer's expiration date of 9/13.
-nine Setopress compression bandages with the manufacturer's expiration date of 9/13.
- one box of 100 Coloscreen Occult Blood Screening Cards with the manufacturer's expiration date of 10/13.

Based on document review and staff interview, the facility staff failed to ensure that facility bylaws were followed for the credentialing and privileging of four (AA, BB, CC, and DD) of four providers serving the facility, and that those providers were recommended for membership in the Medical Staff of the facility. The four providers were not granted privileges according to those bylaws by the governing board of the facility. Findings include:

On 1/29/14 at 10:30 a.m. the surveyor reviewed the credential files of the providers delivering care at the facility. The review of the files revealed that the files did not contain completed applications for membership in the facility medical staff, requests for privileges for each individual provider. In addition, the files did not include documentation or evidence that the information had been reviewed by the medical staff and a positive or negative recommendation had been made to the governing board. The credential files contained no documentation that each individual on the medical staff had been granted membership in the medical staff and were approved for privileges. The records did not contain evidence of reappointment to the medical staff for any of the providers.

The minutes of the monthly governing board meeting minutes from 1/10/12 through 11/12/13 were reviewed. The minutes and agendas reviewed did not indicate that the governing board received information for consideration for the appointment of any of the providers in any of the meeting minutes. The minutes did not document the approval of membership in the medical staff or the granting of privileges to any of the providers listed as active medical staff.

During an interview with staff member H, the office manager, on 1/29/14 at 11:00 a.m., she stated that a contract entity provided the essential information for credentialing to the facility and the medical staff and board made the appointments every two years.

Based on observations, document review, and staff interview, the facility failed to ensure that unusable/expired medications were not available and that medications were appropriately stored in two (Emergency room and Medical floor) of two patient care areas of the hospital. Findings include:

1. The stock medications in the emergency room were reviewed on 1/28/14 at 7:15 a.m. The surveyor noted the following unusable/expired medications:
- one 1.5 gallon container of Go-Lytely with the manufacturer's expiration date of 7/13.
-one, open, partially used 22 gm. tube of Mupurocin ointment with the manufacturer's expiration date of 3/12. No date was written on the tube indicating when it had been opened.
-one open, partially used 30 ml. tube of 2% Xylocaine topical anesthetic with the manufacturer's expiration date of 6/2012. No date was written on the tube indicating when it had been opened.
-one open, partially used, 10 ml. MDV of 1% Xylocaine local anesthetic. No date was written on the vial indicating when it had been opened.
-one open partially used, 10 ml. MDV of 2% Xylocaine local anesthetic. No date was written on the vial indicating when it had been opened.
-three Surgilube 5 gm. foil packets with the manufacturer's expiration date of July 2010.
-nine Surgilube 3 gm. foil packets with the manufacturer's expiration date of Oct. 2013.

The expiration dates and absence of "opened on" dates were verified by staff member A, the facility CEO, on 1/28/14 at 8:10 a.m.

2. On 1/28/14 at 1:00 p.m., the DON escorted the surveyor through the pharmacy department. In the refrigerator there were two boxes of Lorazepam vials 2 ml. The boxes of Lorazepam were not locked up. At 4:30 p.m., during the nightly meeting, the DON stated that this medication had never been doubled locked in the facility.

Review of the facility controlled substance sign out forms revealed that there were no sign out sheets for the Lorazepam.


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On 1/29/14 at 9:00 a.m., the consulting pharmacist was contacted by telephone. The consulting pharmacist stated that he was unaware that this medication was required to be double locked by State law. The door to the pharmacy was locked at all times. The consulting pharmacist stated that he only recommended double locking class I and II medications. Class 3, 4, and 5 drugs were kept in the open stock of medications.

3. The medication refrigerator temperature log was incomplete for December 2013 and January 2014 on 1/28/14 at 1:00 p.m., when the DON escorted the surveyor through the pharmacy department. Based on the instructions on the temperature log sheet, refrigerator temperatures were to recorded twice a day. Forty-eight of 62 opportunities for required temperatures were absent for December 2013. During the month of January 2014 fourty-four of 56 required temperatures for the refrigerator were absent. The DON stated that staff had been not been completing this task and that this concern was now part of the quality assurance program.

Based on staff interviews the hospital failed to develop policies and procedures regarding dietary services provided to patients for 6 out of 6 years. Findings include:

On 1/28/14 at 7:30 a.m., the dietary manager stated that she did not have any policies or procedures for her dietary department.

On 1/29/14 at 1:00 p.m., the contract dietitian stated that she was unaware that the dietary department did not have policies or procedures.

Based on staff interview and document review, the facility failed to ensure that prospective employees were appropriately screened, and licensing authorities were queried regarding background and history prior to employment for 8 (#s B, J, K, L, M, N, O and P) of 8 reviewed employee files. Findings include:

On 1/29/14 at 10:00 a.m. The surveyor reviewed 8 staff member records. All 8 employee records lacked evidence of screening prior to hire.

Staff member B was hired in 2008;
Staff member J was hired in 1999;
Staff member K was hired in 2011;
Staff member L was hired in 2008;
Staff member M was hired in 2002;
Staff member N was hired in 2011;
Staff member O was hired in 2008; and
Staff member P was hired in 2013.

During an interview on 1/29/14 at 10:00 a.m., the DON verified that reference check documentation, background checks and criminal history checks were not a part of employee screening prior to hire. Employee H verified that any reference check documentation would be on the back of the application. No evidence of the performance of reference checks was located in the 8 records reviewed.