HospitalInspections.org

Based on observation, emergency crash cart log review, staff interview, and policy review, the facility failed to ensure emergency equipment, supplies, and medications are readily available for treating emergency cases.

Findings Include:

Observation of the Pediatric Code Cart on 01/31/17 at 11:15 a.m. revealed:
The cart was unlocked;
Two (2) 15 gauge adjustable sternal aspiration needles expired 12/2016;
Two (2) intravenous (IV) extension sets expired 12/2016;
One (1) 18cm (centimeter) Berman Oral Airways expired 6/2016;
One (1) pediatric oxygen mask expired 6/2016; and
Two (2) packs of pediatric quick combo pads expired 9/2016.

Observation of the Adult Code Cart on 01/31/17 at 11:40 a.m. revealed:
Six (6) vials of Epinephrine 1:1000 expired 11/1/16;
Six (6) vials of Lidocaine 1% expired 9/1/16;
One (1) vial adenocard 6mg (milligram)/2ml (milliliter) expired 12/1/16; and
Two (2) vials of Lidocaine 2% expired 10/2016.

Review of the facility's Emergency Crash Cart Log for January 2017 revealed:
On 1/10/17 no check was performed for 7A-7P and 7P-7A;
On 1/15/17 thru 1/18/17 and 1/28/17 thru 1/31/17 no check was performed for 7P-7A.

During an interview on 01/31/17 at 11:45 a.m. the Director of Nurses confirmed the pediatric supplies and medications were expired in the Pediatric Code Cart and Adult Code Cart.

Review of the facility's "Crash Cart" policy (reviewed 02/2015) revealed: "...Procedure... 2. crash carts should be secured with a locking device when not in use. 3. Crash carts in ESD should be check approximately every 12 hours, and after each use. 5. Crash carts in specialty areas should be checked at regularly scheduled intervals, and after each use. 6. Check general crash cart for: c. lock intact; lock number documented with each cart check for each time checked... g. Electrode pads, defibrillator pads and combo electrode packages intact and not outdated."

Based on observation, staff interview, and policy review, the facility failed to ensure drugs and biologicals commonly used in life-saving procedures are in date.

Findings Include:

Observation of the Adult Code Cart on 01/31/17 at 11:40 a.m. revealed:
Six (6) vials of Epinephrine 1:1000 expired 11/1/16;
Six (6) vials of Lidocaine 1% expired 9/1/16;
One (1) vial adenocard 6mg (milligram)/2ml (milliliter) expired 12/1/16; and
Two (2) vials of Lidocaine 2% expired 10/2016.

During an interview on 01/31/17 at 11:45 a.m. the Director of Nurses confirmed the medications were expired in the Adult Code Cart.

Review of the facility's "Crash Cart" policy (reviewed 02/2015) revealed: "...Procedure... 2) crash carts should be secured with a locking device when not in use. 3) Crash carts in ESD should be check approximately every 12 hours, and after each use. 5) Crash carts in specialty areas should be checked at regularly scheduled intervals, and after each use. 6) Check general crash cart for:c) lock intact; lock number documented with each cart check for each time checked...g) Electrode pads, defibrillator pads and combo electrode packages intact and not outdated."

Based on observation, policy review, and staff interview, the facility failed to ensure equipment and supplies commonly used in life-saving procedures are kept in date.

Findings Include:

Observation of the Pediatric Code Cart on 01/31/17 at 11:15 a.m. revealed:
The cart was unlocked;
Two (2) 15 gauge adjustable sternal aspiration needles expired on 12/2016;
Two (2) intravenous (IV) extension sets expired 12/2016;
One (1) 18cm (centimeter) Berman Oral Airway expired 6/2016;
One (1) pediatric oxygen mask expired 6/2016; and
Two (2) packs of pediatric quick combo pads expired 9/2016.

During an interview on 01/31/17 at 11:45 a.m. the Director of Nurses confirmed the pediatric supplies were expired in the Pediatric Code Cart.

Review of the facility's "Crash Cart" policy (reviewed 02/2015) revealed: "...Procedure... 2. crash carts should be secured with a locking device when not in use. 3. Crash carts in ESD should be check approximately every 12 hours, and after each use. 5. Crash carts in specialty areas should be checked at regularly scheduled intervals, and after each use. 6. Check general crash cart for: c. lock intact; lock number documented with each cart check for each time checked... g. Electrode pads, defibrillator pads and combo electrode packages intact and not outdated."

Based on staff interview, review of manufacturer guidelines, and observation, the facility failed to ensure the hospital environment was maintained for the safety of the patients.


Findings Include:


Observation on 2/01/17 at 10:00 a.m. revealed that four (4) of the four (4) Emergency Room (ER) bays and eight (8) of the 25 patient rooms had a Christmas Tree Nut Nipple attached to the O2 (oxygen) flow meter on the wall. After these observations the Respiratory Director stated, "The Christmas Tree Oxygen adapters are multi-patient use. I will call my supplier and have them email me the information."


Review of manufacturer guidelines revealed, "Adapt Nut and Nipple Oxygen Tube Connector Hose Adapter 2555 (also known as Xmas Tree Adapter Oxygen Tube Connector 2555) ... disposable, single-use and latex free..."


In an interview on 02/01/17 at 10:30 a.m. the System Director of Quality stated, "I will remove all Christmas Trees from patient rooms and replace with new ones for patients receiving oxygen. We did not know that they were single use."


By 02/01/17 at 10:40 a.m. all 12 of the Christmas Tree Oxygen Adapters, which had been in use in rooms at 10:00 a.m., had been removed by Respiratory staff. The Hospital Administrator submitted a typed letter on hospital letterhead stating the removal of all Christmas Tree Adapters was complete and all current staff had received education regarding the reason for the replacement and the proper procedure for removal after patient discharge.

Based on temperature and cleaning log review, staff interview, manufacturer guideline review, and policy review, the facility failed to ensure patient-care equipment is maintained in a safe operating condition.

Findings Include:

Review of the facility's January 2017 Hydrocollator Temperature And Cleaning Log and Paraffin Bath Temperature And Cleaning Log revealed no documented evidence of temperature checks or cleanings performed for the Hydrocollator or the Paraffin Bath.

In an interview on 01/31/17 at 12:10 p.m. the Physical Therapy Assistant stated, "Our tech is doing the temperature checks, but I don't think she is writing it down."

Review of the Paraffin Bath Operator's Manual revealed: "... Heating System and Pilot Light Operation: ... The Control Thermostat automatically heats and maintains the paraffin at 130 degrees F (Fahrenheit) [54.4 C (Celcius)] with a +/-4 degrees F variation. ... Cleaning Instructions: Clean the unit after every 40 treatments, when the paraffin is no longer clear, or whenever sediment accumulates on the bottom..."

Review of Hydrocollator Heating Units User Manual revealed, "Caution: ...Never adjust the thermostat too high. The thermostat is extremely sensitive and the slightest adjustment will alter the temperature several degrees. The recommended operating temperature is 160 degrees F to 165 degrees F. [71 degrees to 74 degrees C]. The temperature of the water should be checked with a thermometer after every adjustment before using the HotPac ... Maintenance:... the tank should also be drained and cleaned systematically, at minimum intervals of every two weeks... Cleaning Tips: 1. The interior of the unit should be cleaned, at least every two weeks,..."

Review of the facility's "Rehabilitation Treatment Procedures" policy (revision date January 2016) revealed: ...
D-15 Moist Hot Pack - Policy: Hot packs are warm moist packs applied locally to an area to produce superficial prolonged hyperemia, relief of mascle spasm and pain, relaxation and preparation of further treatment. Hydrocollator is maintained between 150 to 170 degrees ... Procedure: A. Check the unit... 2. The water should be hot, 150 degrees to 170 degrees ... V. Cleaning the unit ... B. Cleaning the Unit and Hot Packs: 1. The unit should be cleaned at least every two weeks...
D-16 Paraffin - Procedure: ..3. Check the temperature of the paraffin- 125-130 degrees.
**This policy contradicts the User Manual for Hydrocolator temperature of 160-165 degrees F.**

Based on observation, staff interview, and policy review, the facility failed to maintain confidentially of patient medical records when not in use.

Findings Include:

Observation on 02/01/17 from 1:25 p.m. to 1:40 p.m. revealed an unattended computer with patient information showing on the screen unattended in the patient hallway.

Interview with Employee #8 on 02/01/17 at 1:55 p.m. confirmed the computer screen with patient information showing was visible in the hallway. She stated that another nurse had called her for help and she ran to help her, forgetting to log off her station.

Review of the facility's "Workstation Usage Guidelines" policy (effective 2/17) revealed: "Objectives:... II. To provide reasonable assurances of protection of the confidentiality and integrity of electronic protected health information... Guidelines: ... N. Users log off the system when they leave the area for a period of time..."

Based on on-call list review, contract/agreement review, policy review, and staff interview, the facility failed to ensure 24-hour emergency dental care is available for all patients by employing a staff dentist or having a contract/arrangement with a dentist to provide services.

Findings Include:

Review of the facility's Emergency Department physician on-call list revealed no documented evidence of a dentist or oral surgeon on the list.

Review of the facility's Contracts/Agreements revealed no documented evidence of a contract or agreement with a dentist or oral surgeon.

During an interview on 2/02/17 at 1:30 p.m. the Administrator stated, "We have a dentist for the nursing home and can use him for these patients also."

Review of the facility's "Dental Services" policy (Reviewed: AUG 2008) revealed: "Policy: Patients will be assisted in obtaining emergency dental care. Procedure: ... 4. If emergency care is needed, and the patient's dentist cannot be reached, the patient may be sent to the (facility name) Emergency Room where the ER physician will call a dentist or oral surgeon on call..."