HospitalInspections.org

A. Based on document review, observation and interview it was determined the Hospital failed to ensure mechanical and electrical equipment available for patient use was inspected and had routine maintenance. This has the potential to affect all patients receiving care at the Hospital.

Findings include:

1. The policy titled "General Equipment Guidelines " (date issued 12/15/1999) was reviewed on 3/3/2015 at 10:00 AM. The policy indicates, " II. Policy; Non-medical equipment will be kept in inventory in a preventive maintenance schedule by the Director of Facilities Management . III. Procedure; b. The manager of the user department will assure safety check has been completed before placing the equipment into use " .

2. A tour of the Sleep Study area was conducted on 5/18/2015 at 4:10 PM with the Sleep Study Supervisor (E #2). It was observed in sleep study room #1 and sleep study room #2 the Bi-Pap-C-Pap equipment did not have a maintenance sticker or an inspection sticker.

3. An interview was conducted on 5/18/2015 at 4:30 PM with E #2. E #2 verified there was not a maintenance sticker or inspection sticker on the Bi-Pap-C-Pap equipment. Also, there is no documentation a routine maintenance check was ever performed.

A. Based on document review, observational tour, and interview it was determined in 1 of 2 anesthesia carts in operating rooms ( cart in room #2) the Hospital failed to ensure drugs were securely stored.
Findings include:

1. The Hospital policy entitled, "Medication Safety Management" (revised 3/13/2014) indicated under, " Policy: 3. Storage 3.2 Medications will be kept in locked areas (unless under constant supervisions). Access to these medications will only be available to those staff who will be administering these medications".

2. On 5/19/15 at 10:00 AM a tour of the the surgical unit was conducted with the Operating Room Manager ( E#4). It was observed in Operating Room #2, that the anesthesia cart was unlocked. The 4th drawer of the unlocked anesthesia cart contained the following :

* one (1) single dose, 1 ml (milliliter) vial of Naloxone HCL injectable

* two (2) single dose, 2 ml vials Fentanyl Citrate injectable

* one (1) 5 ml vial of Flumazenil 0.5 mg/5 ml (0.1/1 mg) injectable

3. On 5/19/15 at 10:00 AM (E #4) stated "the CRNA anesthesia cart should have been locked".

4. On 5/18/15 at 3:10 PM a tour was conducted in the radiology department. It was observed in radiology room #1 and #2 a locked red tackle box sitting on the desk in each room. The red tackle box's contained the following emergency medications:

* 2 (two) Aminophylline 250 mg/ml (milligram/milliliter) injectable
* 2 (two) Ammonia Aspirols Sac
* 1 (one) Diphenhydramine 50 mg/ml injectable
* 2 (two) Epinephrine 1 mg/ml ampule injectable
* 1 (one) Hydrocortisone 100 mg injectable
* 1 Methyprednisoione 125 mg injectable

5. On 5/18/15 at 3:10 PM an interview was conducted with the Radiology Manager (E #5). E#5 verified that the emergency medications/red boxes were not in a secured area.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of the sample validation survey conducted on May 19, 2015, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of NFPA 101 Life Safety Code.

See associated K-tags.

A. Based on documentation/record review, observation, and interview it was determined the hospital failed to ensure medications were properly labeled to ensure safe administration. This failure has the potential to affect all patients receiving care.
Findings include:

1. The Hospital policy entitled, "Multimode Medication Vials/Bottles/Tubes" revised 11/1994)required, "Procedure: 1. Any medication whish is distributed by the pharmacy in multidose packaging (vial,bottle, & tube) will: 1.1 Be dated with the date opened & the expiration date initialed when seal is broken or package opened. 4. Vials found that are not dated as to when they were opened will be discarded".

2. On 5/18/15 at 3:35 PM a tour was conducted with the Director of Physical Therapy (E #6). The following medications were open and did not have a label indicating open date or an expiration date.

*one (1) vial Dexamethasone 120 mg 30 ml vial (4 mg/ml) milligram/milliliter

* one (1) 60 gram 10% Hydrocortisone in Ultrasound Gel jar

3. On 5/18/15 at 3:40 PM, an interview was conducted with E #6. E#6 reported the medications should have been labeled and were not. Therefore, the medications should have been discarded.

Based on document review, observation, and interview, it was determined for 3 of 3 dietary staff ( E#7, #8, #9), the dietician failed to ensure the dietary staff followed established policies and procedures to maintain a sanitary food service environment. This has the potential to affect all patients receiving dietary food services in the hospital.
Findings include:

1. The hospital policy titled "General Safety Guidelines" (implementation date 7/1981) indicates under "39. Always wear an approved hair restraint".

2. On 5/18/15 between between 11:30 AM and 12:30 PM an observational tour was conducted in the dietary department with Chief Operating Officer (E #2). E #7 and
E #8 (cooks) and E #9 (nutritional aid) were wearing hair nets which did not cover all hair. Hair was exposed on the top of head and forehead.

3. E #2 stated during the tour of the dietary department on 5/18/15 at approximately 11:50 AM, "All staff in the kitchen and serving area should be wearing a net hat to cover all their hair."

4. The hospital policy titled "General Safety Guidelines" (implementation date 7/1981) indicates under "42. Any food supplies transferred to another container other than the original must be dated and labeled, unless easily recognized".

5. On 5/18/15 between 9:30 AM and 10:30 AM an observational tour was conducted with the Director of Cardiopulmonary Services (E #3) on the medical surgical unit. The following food items were observed in the Patient Nutrition room without a label or date.

* two (2) slices moldy bread each in individual baggies
* one (1) 30 ml (milliliter) plastic container labeled cinn (cinnamon)
* one (1) 15 ml unlabeled plastic container with a unidentified dark brown substance
* five (5) orange juice 4 ounce containers
* three (3) apple juice 4 ounce containers
* ten (10) unlabeled containers that were identified as applesauce

6. An interview was conducted with E #3 on 5/18/15 at 10-30 AM. E #3 states the food items should have been labeled and dated.

7. The hospital policy titled "General Safety Guidelines" (implementation date 7/1981) was reviewed on 5/18/15 at 12:00 PM. The policy indicated under "41. Any food supplies must be dated upon arrival, placed in a manner designed to assure "First in, first out" usage".

8. On 5/18/15 between 11:30 AM and 12:30 PM a tour of the dietary department was conducted with the Chief Operational Officer (E #2). It was observed that the following food items were found in the refrigerator and did not indicate a use by or expiration date.

* 30 boiled eggs
* a large plastic bag containing cooked bacon
* container of sliced tomatoes
* plastic bag containing sliced ham

9. An interview was conducted with the cook (E #7) on 5/19/2015 at 11:00 AM. E #7 stated there is not a policy stating how long to keep food items once they are opened. We know to throw away the boiled eggs in three days but there is no policy. I am unaware of a use by date policy.

10. An interview was conducted with the Chief Operational Officer (E #2) on 5/19/15 at 11:30 AM. E #2 states we do not have a policy addressing a use by date or expiration date for food. We are going to develop a policy addressing a use by date.

B. Based on document review, observation and interview, it was determined the hospital failed to ensure Dietitian consultations were completed. This has the potential to affect all patients requiring a dietary consultation.

1. The hospital policy titled "Dietitian On Call" (implementation date 4/26/2011) was reviewed on 5/20/15 at 11:50 AM. "The policy indicated under 3. When the Clinical Dietitian is on vacation, a consultant dietitian will be on call...".

2. Pt # 2 was admitted to the medical surgical unit on 5/17/15 with a diagnosis of chronic obstructive pulmonary disease. The Initial Interview completed by the registered nurse generated an automatic order for the Dietitian to review nutritional needs, high risk. As of 5/20/15 at 11:50 AM the On Call Dietitian had not been notified of the consultation order. Pt #2 is anticipated to be discharged at 1:00 PM 5/20/15.

3. An interview was conducted with the Unit Secretary (E #10) on 5/20/15 at 11:20. E #10 stated when the Dietitian referral is "automatically generated by the computer I do not know about it, therefore I do not know to call the Dietician".

4. An interview was conducted with the registered nurse (E #11) assigned to Pt #2,. E #11 stated an email was received notifying the Dietitian was on vacation, but the on call Dietitian was not notified of the consult for Pt #2.