HospitalInspections.org

Based on a tour of the facility 4-27-10, the facility did not have a preventive maintenance program in place to ensure that all essential mechanical, electrical and patient care equipment was maintained in safe operating condition.

Findings were:

During a tour of the emergency room on 4-27-10, there was no documentation to indicate that crash cart checks had been performed 9 of the 52 required times thus far for the month of April 2010 on the crash cart in ER room #2.

During a tour of the emergency room on 4-27-10, there was no documentation to indicate that crash cart checks had been performed 11 of the 52 required times thus far for the month of April 2010 on the crash cart in ER room #3.

During a tour of the emergency room on 4-27-10, 1 of 1 refrigerator in the medication room contained no documentation to indicate that temperature checks had been performed on 35 of the 117 days for the time period of 1-1-10 through 4-27-10.

During a tour of the surgical area on 4-27-10, 1 of 1 refrigerator in the medication room contained no documentation to indicate that temperature checks had been performed on 35 of the 117 days for the time period of 1-1-10 through 4-27-10.

During a tour of the kitchen on 4-27-10, 1 of 4 fluorescent light fixtures above the steam table was not in working order.

During a tour of the kitchen on 4-27-10, twice-daily temperature documentation for 1 of 2 freezers indicated that the freezer temperature had been outside the acceptable range for 42 of the 53 times checked thus far in the month of April 2010 but that no corrective action had been taken.

During a tour of the kitchen on 4-27-10, twice-daily temperature documentation for 1 of 2 refrigerators ( " double-door fridge " ) indicated that the refrigerator temperature had been outside the acceptable range 40 of the 52 times checked thus far in the month of April 2010 but that no corrective action had been taken.

During a tour of the kitchen on 4-27-10, twice-daily temperature documentation for 1 of 2 refrigerators ( " single-door fridge " ) indicated that the refrigerator temperature had been outside the acceptable range 39 of the 52 times checked thus far in the month of April 2010 but that no corrective action had been taken.

The above was confirmed with the Administrator and Chief Nursing Officer during a meeting held the afternoon of 4-27-10 in the Administrator ' s office.

Based on a tour of the facility on 4-27-10, the facility did not have a preventive program in place to ensure that there was proper lighting and temperature control in all pharmaceutical, patient care and food preparation areas.

Findings were:

During a tour of the emergency room on 4-27-10, 1 of 1 refrigerator in the medication room contained no documentation to indicate that temperature checks had been performed on 35 of the 117 days for the time period of 1-1-10 through 4-27-10.

During a tour of the surgical area on 4-27-10, 1 of 1 refrigerator in the medication room contained no documentation to indicate that temperature checks had been performed on 35 of the 117 days for the time period of 1-1-10 through 4-27-10.

During a tour of the kitchen on 4-27-10, 1 of 4 fluorescent light covers above the steam table was not in working order.

During a tour of the kitchen on 4-27-10, twice-daily temperature documentation for 1 of 2 freezers indicated that the freezer temperature had been outside the acceptable range for 42 of the 53 times checked thus far in the month of April 2010 but that no corrective action had been taken.

During a tour of the kitchen on 4-27-10, twice-daily temperature documentation for 1 of 2 refrigerators ( " double-door fridge " ) indicated that the refrigerator temperature had been outside the acceptable range 40 of the 52 times checked thus far in the month of April 2010 but that no corrective action had been taken.

During a tour of the kitchen on 4-27-10, twice-daily temperature documentation for 1 of 2 refrigerators ( " single-door fridge " ) indicated that the refrigerator temperature had been outside the acceptable range 39 of the 52 times checked thus far in the month of April 2010 but that no corrective action had been taken.

The above was confirmed with the Administrator and Chief Nursing Officer during a meeting held the afternoon of 4-27-10 in the Administrator ' s office.

Based on a review of facility documentation, the facility did not assure the safety of patients during non-medical emergencies by properly training staff in handling emergencies.

Findings were:

During a review of documentation on 4-26-10, it was discovered that only 6 of the 12 fire drills required during the time period of 4-1-09 through 3-31-10 had been performed.

Facility policy titled Life Safety, Emergency Preparedness and Fire Drills states, in part, "Fire drills will be held monthly."

The above was confirmed with the Administrator and Chief Nursing Officer during a meeting held the afternoon of 4-27-10 in the Administrator ' s office.

Based on a review of documents and a tour of the facility, the governing body was not responsible for implementing and monitoring policies concerning the facility's total operation and for ensuring that the policies were administered so as to provide quality health care in a safe environment.

Findings were:

Facility policy titled Medication Management states, in part, " For this policy, medication includes prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals, over-the-counter drugs, vaccines, diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral nutrition, blood or blood derivatives, intravenous solutions (plain, with electrolytes and/or drugs); and any product designated by the Food and Drug Administration (FDA) as a drug. The definition of medication does not include enteral nutrition solutions, oxygen and other medical gases. "

II Storage
A. " ...Refrigerator temperatures are checked and recorded on a regular basis to ensure the stability of medications stored there. "

B. Vials
4. " The individual making the initial entry into a multi-dose vial will date
the bottle the date the first entry was made and initial the label. "

5. " After the initial entry, multiple-use vials may be used up to the time specified in the manufacturer ' s product information for the specific drug or product. "

During a tour of the emergency room on 4-27-10, 1 of 1 refrigerator in the medication room contained no documentation to indicate that temperature checks had been performed on 35 of the 117 days for the time period of 1-1-10 through 4-27-10.

During a tour of the surgical area on 4-27-10, 1 of 1 refrigerator in the medication room contained no documentation to indicate that temperature checks had been performed on 35 of the 117 days for the time period of 1-1-10 through 4-27-10.

During a tour of the patient care unit on 4-27-10, 1 of 1 vial of influenza vaccine (Fluvirin) found in 1 of 1 medication refrigerator had been opened 2-18-10 but was still available for patient use. Per the manufacturer's recommendations (found on micromedex.com), "once the multiple-dose vial is pierced, use within 28 days."

During a tour of the emergency room on 4-27-10, 1 of 1 multi-dose vial of Tuberculin PPD found in 1 of 1 medication refrigerator had been accessed but had not been initialed or dated.

Facility policy titled Informed Consent states, in part, " It is the policy of Ward Memorial Hospital that the patient must be given the opportunity to give an " informed consent " prior to the administration of anesthesia and prior to the performance of operative and/or invasive procedures, diagnostic or therapeutic procedures or situations when it is deemed advisable to have formal documentation of the patient ' s consent for treatment. "

During a review of clinical records on 4-26-10, 1 of 4 surgical records (patient #4) contained a surgical consent signed by a party other than the patient, with no documentation to support that anyone other than the patient was responsible for medical decisions or that the surgery was performed due to a medical emergency.

Facility policy titled Crash Carts states, in part, " A. 3. Shift Checks: a. Every shift on nurse will check the crash carts for: 1. patency of the lock, 2. monitor-electrical hookup to the outlet, 3. defibrillator function, 4. ambu bag. b. After the nurse has checked the cart, he/she will then document this check by signing the crash cart check form in the appropriate area.

During a tour of the emergency room on 4-27-10, there was no documentation to indicate that crash cart checks had been performed 9 of the 52 required times thus far for the month of April 2010 on the crash cart in ER room #2.

During a tour of the emergency room on 4-27-10, there was no documentation to indicate that crash cart checks had been performed 11 of the 52 required times thus far for the month of April 2010 on the crash cart in ER room #3.

Facility policy titled Life Safety, Emergency Preparedness and Fire Drills states, in part, " Fire drills will be held monthly. "

During a review of documentation on 4-26-10, it was discovered that only 6 of the 12 fire drills required during the time period of 4-1-09 through 3-31-10 had been performed.

The above was confirmed with the Administrator and Chief Nursing Officer during a meeting held the afternoon of 4-27-10 in the Administrator ' s office.

Based on a tour of the facility, outdated, mislabeled or otherwise unusable drugs were available for patient use.

Findings were:

Facility policy titled Medication Management states, in part, " For this policy, medication includes prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals, over-the-counter drugs, vaccines, diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral nutrition, blood or blood derivatives, intravenous solutions (plain, with electrolytes and/or drugs); and any product designated by the Food and Drug Administration (FDA) as a drug. The definition of medication does not include enteral nutrition solutions, oxygen and other medical gases. "

II Storage

B. Vials
4. " The individual making the initial entry into a multi-dose vial will date
the bottle the date the first entry was made and initial the label. "

5. " After the initial entry, multiple-use vials may be used up to the time specified in the manufacturer ' s product information for the specific drug or product. "

During a tour of the patient care unit on 4-27-10, 1 of 1 vial of influenza vaccine (Fluvirin) found in 1 of 1 medication refrigerator had been opened 2-18-10 but was still available for patient use. Per the manufacturer's recommendations (found on micromedex.com), "once the multiple-dose vial is pierced, use within 28 days."

During a tour of the emergency room on 4-27-10, 1 of 1 multi-dose vial of Tuberculin PPD found in 1 of 1 medication refrigerator had been accessed but had not been initialed or dated.

During a tour of the emergency room on 4-27-10, 13 of 15 culture swabs in ER room #2 had expired 2-10 but were still available for patient use.

During a tour of the emergency room on 4-27-10, 1 of 4 lab collection tubes in ER room #2 had expired 1-10 but were still available for patient use.

The above was confirmed with the Administrator and Chief Nursing Officer during a meeting held the afternoon of 4-27-10 in the Administrator ' s office.

Based on a review of documents, the facility did not maintain medical records that included, as applicable, evidence of properly executed informed consent forms.

Findings were:

During a review of clinical records on 4-26-10, 1 of 4 surgical records (patient #4) contained a surgical consent signed by a party other than the patient, with no documentation to support that anyone other than the patient was responsible for medical decisions or that the surgery was performed due to a medical emergency.

During a review of clinical records on 4-26-10, 2 of 14 emergency records (patients #7 & #14) contained consents for treatment signed by parties other than the patient, with no documentation to support that anyone other than the patient was responsible for medical decisions or that the patient was incapacitated in any way due to an emergent condition.

The above was confirmed with the Administrator and Chief Nursing Officer during a meeting held the afternoon of 4-27-10 in the Administrator ' s office.