HospitalInspections.org

Based on interview, registration packet review and policy review, the facility failed to ensure the contact information for the state agency was included in the Patient's Rights and Responsibilities.

Findings include:

- On 3/11/14, at 10:15 AM, Employee #11, Admitting Registrar, described the registration process and provided a copy of the Patient's Rights and Responsibilities. Employee #11 indicated all patients were provided this information upon registration.

- Review of the Patient's Rights and Responsibilities revealed the contact information for the state agency was not listed as one of the agencies to call for complaints and concerns. The "Notice of Privacy Practices" with a section about "Complaints" on the back side, did not provide the state agency's contact information.

- Review of the policy on Complaint and Grievance Process (revised 1/2014), revealed the information regarding how to file a complaint or grievance included the state agency's contact information. The Patient Guide had an insert with information on who to call for safety or quality of care issues, which included the state agency. However, the Patient's Rights and Responsibilities found in the registration packet did not include the state agency's contact information.

Based on observation and interview, the facility's recovery nurses in the surgical services area failed to maintain a usable supply of Demerol 75 milligrams for post-surgical patients.

Findings include:

On 3/13/14 at 11:50 AM, nine expired Carpuject cartridges of Demerol 75 milligrams were observed.

The NDC number on each cartridge was 0409-1179-30. The lot number on each cartridge was 14560LL. The expiration date on each cartridge was 2/1/14.

Note: The charge nurse removed the Demerol cartridges from use when notified.

Based on a review of pages titled, "Pathology Specimen Log Book," patient electronic medical records, and a procedure titled, "Specimen Preparation and Handling," with the administrative laboratory director, the laboratory did not follow written protocol for the receipt and reporting of tissue specimens results.

Findings include:

--Of the 18 entries reviewed from the Pathology Specimen Log Book, 3 entries did not have a unique patient identifier, ordering physician, specimen source, date and time of collection as stated in the Specimen Preparation and Handling procedure.
--Of the 18 entries reviewed from the Pathology Specimen Log Book, 7 entries did not have a date that the pathology report was received. Of the 7 entries, 3 electronic patient medical records reviewed did not have the pathology report for the specimens submitted.
--The laboratory did not have a system in place to track overdue pathology reports and ensure that pathology reports were entered into the patients' medical record.

Based on observation and interview, the facility's kitchen staff failed to consistently label opened, unused food items in its walk-in cooler.

Findings include:

On 3/11/14 at 9:15 AM, observation in the kitchen's walk-in cooler revealed the following opened, unlabeled food items without clear open/expiration dates:

--Four blocks of individually sliced American cheese.
--One block of individually sliced Swiss cheese.
--A package of shredded mozzarella cheese.
--A package of whipped topping.
--Six prepared fruit cups.
--A package of coleslaw.
--Sliced tomatoes with lettuce in a container.
--A package of bistro-type lettuce.

The Kitchen Manager/Dietitian indicated kitchen staff would discard and/or label the items as appropriate.

Based on observation and interview, the facility's cardiopulmonary rehabilitation services failed to maintain a defibrillator located in the facility's therapy gym, and based on observation, the facility failed to ensure the locking mechanism to the Behavioral Health Unit's (BHU) Seclusion Room was working properly.


Findings include:

On 3/12/14 at 4:10 PM, observation revealed the facility's defibrillator check sheet was blank for March 3, 11, and 12, 2014.

The Director of Cardiopulmonary rehabilitation indicated the defibrillator checks were done daily, but in this case, the checks were not completed.

The rhythm strip printed and still attached to the defibrillator showed 1:13 PM on 3/10/14.

The Director of Cardiopulmonary Rehabilitation indicated the EKG technician was responsible for the missed checks. The technician was unavailable for interview.



30457


On 4/11/14 at 4:40 PM in the facility's BHU, it was observed that the 3-point, latching hardware on the door to the seclusion room was malfunctioning. When the handle was released, a spring within the mechanism failed to return completely to the open (unlatched) position. This condition would lock a patient within the room. (Note: Even with staff in attendance, there was no assurance that a patient within the Seclusion Room could exit to seek safety.)

Based on medical record review and policy review, the facility failed to report the death of 1 of 30 patients to the organ procurement organization (Patient #16).

Findings include:

Patient #16

Patient #16 was admitted on 2/19/14, with diagnoses including congestive heart failure (not otherwise specified), renal/kidney failure and acute pulmonary edema. Patient #16 expired on 2/22/14 at 2:40 PM.

- Review of medical records revealed there was no documented evidence the Intermountain Organ Recovery System was notified of Patient #16's death.

- Review of the policy on Organ and Tissue Donations (revised 11/2009) that stated in part: "...Consisted with its obligations under State and Federal laws and with the rights of the individual patient, Northeastern Nevada Regional Hospital will report ALL DEATHS to Intermountain Organ Recovery System (IORS), the local Organ Procurement Organization (OPO), for evaluation for potential organ/tissue donation..."