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Based on observation, interview and policy and procedure review the facility failed to ensure that equipment and supplies commonly used in life-saving procedures were maintained and monitored. Findings include:

During observation on 5/7/12 at approximately 1400 it was found on the Acute Care unit that the crash cart was not checked for supply expiration dates and the following supplies were found to be expired:
1. Four Carbon Dioxide (CO2) detectors that had expired 12/11
2. One CO2 pediatric detector that had expired 6/11
3. One Endotracheal Tube (ET) inducer that had expired 4/10
4. Two ET stylettes that had expired 4/06
5. One Arterial Blood Gas collection kit that had expired 4/12
6. One Tracheal tube that had expired 2/03
7. One Combi-tube Esophageal/Tracheal Airway kit that had expired 11/10
Staff A and B confirmed these findings at the time of occurrence.


During policy and procedure review on 5/8/12 at approximately 1530 it was found in the policy titled, "Code Blue-Emergency Resuscitation", states under the section Emergency Cart/Defibrillator Safety Checks, "Cart will be opened and checked for contents monthly and following each use. Floor staff will replace the supplies/Pharmacy will check drugs. A new lock will be placed. Sterile items will be checked for package integrity and expiration date. Items with expiration dates expiring within the month will be replaced".

During the tour of the Emergency Department it was determined that crash carts were not being monitored and maintained according to policy. Monthly checks were not being performed.

Staff A confirmed these findings.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 5/10/2012, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 for each building, dated 5/10/2012 for Life Safety Code.

Based on medical record review and interview the facility failed to ensure medical records were completed within 30 days of discharge and failed to ensure telephone orders were authenticated within 48 hours resulting in the potential for failure to identify errors in the medical chart.

On 05/09/2012 at approximately 1600 during medical record review it was revealed in 1 of 2 swing bed records (#19) the physician had not authenticated telephone orders placed on 02/23/2012 at 2115 until 05/02/2012 at 1049. During an interview with staff A on 05/09/2012 at approximately 1615 the findings were confirmed.


29313

During an interview on 5/8/12 at approximately 0930 it was confirmed by staff C and D that the facility has 44 discharged patients medical records that are incomplete beyond the thirty day requirement.
During policy and procedure review on 5/8/12 at approximately 1500 it was found in the policy titled, "Incomplete Medical Records", it states, "Medical records of discharged patients are completed within a period of time that in no event exceeds 30 days following discharge".

Based on observation and interview the facility failed to provide safeguards for records, presenting the risk for damage and against loss. Findings include:

During observation of the medical records area on 5/8/12 at approximately 0915 it was observed that multiple boxes of medical records waiting to be scanned into the computer were on the floor and at risk for damage or destruction.

During and interview of Staff D it was confirmed that the boxes should not be stored on the floor and that if the facility were to have a flood...etc, that these records would be damaged and/or destroyed.

Based on document review and interview the facility failed to have a quality assurance program that included the evaluation of action plans set in place for quality improvement resulting in the potential to fail to improve upon quality issues identified as being in need of improvement. Findings include:

On 05/09/2012 at approximately 1100 during document review it was revealed the facility's quality assurance program did not have a timeline for the reassessment of improvement measures. Each department identified areas for improvement and goals set for improvement but failed to establish timelines for which the goals were to be reanalyzed.

On 05/09/2012 at approximately 1100 during an interview with the Director of Quality confirmed the quality assurance program had not established definitive timelines for analysis of action plans and monitoring. The timelines for reanalysis were "ongoing".