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Tag No.: A0341
Based on document review and interview, it was determined for 1 of 1 (MD#4) Emergency Department Physician file reviewed, the Hospital failed to ensure the physician was credentialed/privileged for the administration and/or monitoring of conscious sedation was granted. This has the potential to affect all patients that receive care in the Emergency Department with an average of 20 patients daily.
Findings include:
1. The policy titled "Administration of Sedation (I.V. (Intravenous) Conscious Sedation)" (issued by the facility, 1/10/14) was reviewed on 11/12/21. The policy noted "Qualifications for Administration and Monitoring IV Conscious Sedation: ... 2. Monitored according to guidelines by credentialed personnel... 2... Only those physicians who have been credentialed may be prescribe and manage medications used to achieve sedation."
2. The credentialing file for MD#4 was reviewed on 11/10/2021 at approximately 1:00 PM. The "Delineation of Privileges... Emergency Department Physician Privileges" dated 9/7/2020 lacked documentation privileges for IV conscious sedation were requested or granted.
3. During an interview on 11/9/2021 at approximately 9:45 AM, the Vice President of Quality and Community Services (E#11) stated the Emergency Department, Intensive Care unit and the Endoscopy Lab were the departments where IV conscious sedation could be administered.
4. During an interview on 11/10/2021 at approximately 2:30 PM, the Medical Staff Coordinator (E#10) verbally agreed the Emergency Department Physician Privilege form lacked an IV conscious sedation option. E#10 stated "None of the ED (Emergency Department) Physicians would be credentialed since it's (IV conscious sedation) not an option on the form." E#10 verbally agreed MD#4 was not credentialed and should have been.
Tag No.: A0405
Based on document review and interview, it was determined for 2 of 2 (E#7, E#8) Emergency Department Registered Nurses and 4 of 4 (MD#1, MD#2, MD#3, MD#4) Physicians personnel files reviewed, the Hospital failed to ensure staff were qualified to administer conscious sedation. This has the potential to affect all patients that receive care in the Emergency Department, Intensive Care Unit and Endoscopy Laboratory.
Findings include:
1. The policy titled "Administration of Sedation (I.V. (Intravenous) Conscious Sedation)" (issued, by the facility, 1/10/14) was reviewed on 11/12/21. The policy noted "Qualifications for Administration and Monitoring IV Conscious Sedation: ... All persons are responsible for maintaining proficiency skills necessary to provide quality patient care, prior to administering and monitoring sedation... Administration and/or monitoring sedation may be performed by a qualified physician or a registered nurse under the direct supervision of a physician... Nurses who have not demonstrated competency may not administer medications or monitor patients during sedation... a. completion of written exam annually; b. use of cardiac monitor and defibrillation; c. knowledge of medications, adverse reactions and reversal agents; d knowledge of potential complications; and e. ACLS (Advanced Cardiac Life Support) and PALS (Pediatric Advanced Life Support" certification required..."
2. The following personnel/physicians files were reviewed on 11/10/2021 and lacked documentation of sedation competency:
a) E#7, Date of Hire (DOH): 1979
b) E#8, DOH: 2018
c) MD#1, last credentialed: 12/20/2020
d) MD#2, last credentialed: 5/4/2020
e) MD#3, last credentialed: 1/22/2020
f) MD#4, last credentialed: 9/7/2020
3. During an interview on 11/10/2021 at approximately 2:30 PM,. the Medical Staff Coordinator (E#10) verbally agreed the physicians' who were credentialed to administer IV conscious sedation did not receive conscious sedation training and should have been.
4. During an interview on 11/9/2021 at approximately 9:45 AM, the Vice President of Quality and Community Services (E#11) stated the Emergency Department, Intensive Care unite and the Endoscopy lab were the departments where IV conscious sedation could be administered. On 11/12/2021 at approximately 12:00 PM, E#11 verbally agreed IV conscious sedation competency had not been conducted annually and should have been for the 8 Intensive Care unit staff, 13 Emergency Department staff and 6 Endoscopy Lab nurses, and all physicians in the retrospective units.
Tag No.: A0700
Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Recertification survey conducted on November 15, 2021, the facility failed to provide and maintain a safe environment for patients, staff and visitors.
This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.
Tag No.: A0710
Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Recertification survey conducted on November 15, 2021, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags.
Tag No.: A0724
Based on observation, document review, and staff interview, it was determined the Hospital failed to ensure outdated or expired supplies were not available for patient use. This has the potential to affect all patients receiving care at the Hospital with an average daily census of 15 patients.
Findings include:
1. The policy titled "Inventory Management (date issued by the facility, June 4, 2020)" was reviewed on 11/10/21 at approximately 10:15 AM. The policy noted "... All expired product will be removed and disposed of immediately..."
2. During a tour of the Newborn Nursery on 11/9/21 at approximately 1:45 PM, with the Director of Obstetrics (E#9), the following were observed to be expired on the crash cart on the following dates:
a) 2- disposable fiber optic laryngoscopes dated 3/21/21
b) 2- suction tubing's dated 11/1/21
c) 2- carbon monoxide detectors dated 4/14/21
d) 2- nasogastric tubes size 2.5 dated 10/17/21
e) 1- nasogastric tube size 3.0 dated 9/28/21
f) 2- luer locks dated 6/30/21
3. During the tour an interview was conducted with E#9, E#9 verbally agreed the items were expired and should have been removed from the crash cart.
Tag No.: A0750
A. Based on observation, document review, and staff interview, it was determined the Hospital failed to ensure 1 of 1 sharp container was replaced when the fill line had been reached. This has the potential to affect all staff and patients treated by the Hospital.
Findings include:
1. The policy "Sharps Disposal" (revised by the facility, December 29, 2017) was reviewed 11/9/21 at approximately 3:00 PM. The policy noted "Sharps containers in other work areas... are to be maintained by departmental staff and changed by the employee working in that area... filled containers are to be closed, locked and placed in the Biohazard Waste container for disposal."
2. An observational tour of the medical/surgical unit was conducted on 11/9/21 at approximately 11:30 AM, with the Director of the Medical/Surgical (E#6) unit. The sharps container located on the side of the crash cart was observed to be full, past the "fill line" and the lid was unable to be closed.
3. An interview was conducted with E#6 on 11/9/21 at approximately 11:45 AM. E#6 agreed with the above finding stating, "yes, the sharps container should not be that full and still in use".
B. Based on observation and staff interview it was determined the Hospital failed to ensure equipment was properly stored to prevent cross contamination. This has the potential to affect all staff and patients treated by the Hospital.
Findings include:
1. An observational tour of the medical/surgical unit was conducted on 11/9/21 at approximately 11:30 AM with the Director of the medical/surgical unit (E#6). During the tour of the "Clean Utility Closet", 4 IV (intravenous) pumps were observed on the floor plugged into an outlet and available for patient use.
2. An interview was conducted with E#6 on 11/9/21 at approximately 11:35 AM. E#6 agreed with the above finding stating, "No the IV pumps should not be setting directly on the floor".
C. Based on document review, observational tour, and staff interview it was determined the Hospital failed to ensure expired food items were discarded from stock. Approximately 3 of 20 seasoning substances in the kitchen, were labeled with an open date greater than 1 year prior, thus failing an acceptable level of safety and quality.
Findings include:
1. On 11/10/21 at approximately 2:00 PM, the policy titled "Date Marking Ready-To-Eat, Potentially Hazardous Food" (reviewed/revised by the facility, 9/25/2020) was reviewed. The policy noted in Section III, #9, "Spices will be labeled with the date that the product is opened and a one year discard date from the open date."
2. On 11/9/21 at approximately 3:15 PM, an observational tour of the Dietary Services Department was conducted with the Food Services Director (E#5). During the tour, 3 seasoning substances (Ground Oregano, Chopped Chives, and Ground Ginger) were observed to have opened dates greater than 1 year old.
3. E#5 stated during an interview conducted on 11/9/21 at approximately 3:20 PM, the three seasonings (Ground Oregano, Chopped Chives, and Ground Ginger) had not been discarded and should have been by the 1 year date from the opened label.