HospitalInspections.org

Based on policy review and staff interview the hospital failed to provide a policy that only properly trained personnel are given the responsibility of inserting and maintaining urinary catheters. This deficient practice had the potential for patients to receive substandard care.

Findings Included:

- Policy review on 2/8/2017 at 4:00 PM revealed the hospital failed to ensure they had a policy and procedure that only trained personnel are given the responsibility to perform the insertion and maintainence of urinary catheters.

Quality/Risk Manager Staff A interviewed on 2/8/2017 at 2:00 PM indicated they do not have a policy on who is allowed to insert Foley catheters and maintain them.

Based on staff interview, medical record review, and document review the hospital failed to ensure verbal orders were used infrequently for 20 of 20 medical records reviewed (Patient #'s 1-20). This deficient practice had the potential to cause inaccurate orders, which could lead to patient harm.

Findings include:

- Patient #1's medical record review on 2/7/2017 revealed the patient was admitted on 3/6/2016 and discharged on 3/11/2016 with a diagnosis of Stenosis (narrowing of open spaces in the lower spine and Myelopathy (a nervous system disorder that affects the spinal cord). Physician Staff G placed 15 verbal orders on 3/7/2016, 3 on 3/8/2016. Physician Staff K placed 37 verbal orders on 3/7/2016, 3 on 3/9/2016, 2 on 3/10/2016, and 1 on 3/11/2016.

- Patient #2's medical record review on 2/7/2017 revealed the patient was admitted on 6/28/2016 and discharged on 6/28/2016 with a diagnosis of Poor Wound Healing. Physician Staff F placed 16 verbal orders on 6/28/2016 and Advanced Practice Registered Nurse (APRN) Staff J placed 26 verbal orders on 6/28/2016.

- Patient #3's medical record review on 2/7/2017 revealed the patient was admitted on 1/16/2017 and discharged on 1/16/2017 with a diagnosis of Stress urinary incontinence (loss of bladder control). Physician Staff D placed 15 verbal orders on 1/16/2017.

- Patient #4's medical record reviewed on 2/7/2017 revealed the patient was admitted on 9/7/2016 and discharged on 9/7/2016 with a diagnosis of Post laminectomy Syndrome (failed back surgery syndrome). Physician Staff S placed 16 verbal orders on 9/7/2016 and Physician Staff N placed 11 verbal orders on 9/7/2016 and Physician Staff L placed 1 verbal order on 9/7/2016.

- Patient #5's medical record review on 2/7/2017 revealed the patient was admitted on 7/11/2016 and discharged on 7/12/2016 with a diagnosis of Post Laminectomy Syndrome (failed back surgery syndrome). Physician Staff P placed 37 verbal orders on 7/11/2016 and 5 verbal orders on 7/12/2016.

- Patient #6's medical record review on 2/7/2017 revealed the patient was admitted on 2/29/2016 and discharged on 3/2/2016 with a diagnosis of Left Knee Pain. Physician Staff E placed 16 verbal orders on 2/29/2016 and 7 verbal orders on 3/1/2016. Physician's Assistant Staff T placed 60 verbal orders on 2/29/2016 and 1 verbal order on 3/2/2016.

- Patient #7's medical record review on 2/7/2017 revealed the patient was admitted on 3/17/2016 and discharged on 3/19/2016 with a diagnosis of Bilateral PARS Defect (a spinal disorder in which a bone slips forward onto the bone below). Physician Staff F placed 15 verbal orders on 3/17/2016, Physician Staff L placed 1 verbal order, and Physician's Assistant Staff J placed 32 verbal orders on 3/17/2016 and 3 verbal orders on 3/18/2016.

- Patient #8's medical record review on 2/7/2017 revealed the patient was admitted on 3/30/2016 and discharged on 4/2/2016 with a diagnosis of Stenosis and Anterolisthesis (a condition in the upper spine where the area in front of the vertebrae slips forward). Physician Staff G placed 14 verbal orders on 3/30/2016, 5 verbal order on 3/31/2016, and 2 verbal orders on 4/1/2016, Physician's Assistant Staff K placed 36 verbal orders on 3/30/2016 and 5 verbal orders on 4/1/2016. Physician Staff M placed 1 verbal order on 3/31/2016.

- Patient #9's medical record review on 2/7/2017 revealed the patient was admitted on 5/16/2016 and discharged on 5/18/2016 with a diagnosis of Right Hip Arthroplasty (surgical reconstruction or replacement of a joint). Physician Staff E placed 17 verbal orders on 5/16/2016 and Physician's Assistant Staff T placed 59 verbal orders on 5/17/2016 and 1 verbal order on 5/18/2016.

- Patient #10's medical record review on 2/7/2017 revealed the patient was admitted on 5/20/2016 and discharged on 5/20/2016 with a diagnosis of a Post of Hematoma (swollen collection of clotted blood). Physician Staff B placed 21 verbal orders on 5/20/2016. Physician's Assistant Staff M placed 1 verbal order on 5/20/2016 and 1 on 5/21/2016, and Physician Staff L placed 1 verbal order on 5/20/2016.

- Patient #11's medical record review on 2/7/2017 revealed the patient was admitted on 7/14/2016 and discharged on 7/17/2016 with a diagnosis of Right Hip Pain. Physician Staff E placed 21 verbal orders on 7/14/2016 and 1 verbal on 7/17/2016 and Physician's Assistant Staff T placed 60 verbal orders on 7/14/2016.

- Patient #12's medical record review on 2/7/2017 revealed the patient was admitted on 7/14/2016 and discharged on 7/16/2016 with a diagnosis of Spondylolisthesis (a spinal disorder in which a bone slips forward onto the bone below it). Physician Staff O placed 11 verbal orders on 7/14/2016, 2 verbal orders on and 7/15/2016. APRN Staff U placed 18 verbal orders on 7/14/2016, 8 verbal orders on 7/15/2016, and 2 verbal orders on 7/16/2015. Physician's Assistant Staff V placed 1 verbal order on 7/16/2016.

- Patient #13's medical record review on 2/7/2017 revealed the patient was admitted on 8/23/2016 and discharged on 8/24/2016 with a diagnosis of Herniated Disc (a problem with the rubbery disc between the spinal bones). Physician Staff B placed 15 verbal orders on 8/23/2016 and Physician's Assistant Staff I placed 2 verbal orders on 8/24/2016.

- Patient #14's medical record review on 2/7/2017 revealed the patient was admitted on 2/8/2016 and discharged on 2/10/2016 with a diagnosis of Right Knee Pain. Physician Staff C placed 68 verbal orders on 2/8/2016, 3 verbal orders on 2/9/2016, and 4 verbal orders on 2/10/2016.

- Patient #15's medical record review on 2/7/2017 revealed the patient was admitted on 5/4/2016 and discharged on 5/6/2016 with a diagnosis of Left Knee Unilateral Primary Osteoarthritis (a non-inflammatory disease of the knee joint). Physician Staff F placed 76 verbal orders on 5/4/2016, 2 verbal orders on 5/5/2016, and 5 on 5/6/2016.

- Patient #16's medical record review on 2/7/2017 revealed the patient was admitted on 8/26/2016 and discharged on 8/30/2016 with a diagnosis of with a diagnosis of Post laminectomy Syndrome (failed back surgery syndrome). Physician Staff P placed 15 verbal orders on 8/30/2016.

- Patient #17's medical record review on 2/7/2017 revealed the patient was admitted on 9/7/2016 and discharged on 9/8/2016 with a diagnosis of Herniated Nucleus Pulposus (a problem with the rubbery disc between the spinal bones). Physician Staff H placed 15 verbal orders on 9/7/2016 and 1 verbal order on 9/8/2017. Physician's Assistant Staff W placed 34 verbal orders on 97/2016 and 1 verbal order on 9/8/2016.

- Patient # 18's medical record review on 2/7/2017 revealed the patient was admitted on 10/4/2016 and discharged on 10/4/2016 with a diagnosis of Retained Drain Fragment (a piece of medical equipment designed to remove fluid from the inside of a patient's body). Physician Staff H placed 15 verbal orders on 10/4/2016 and Physician's Assistant Staff W placed 25 verbal orders on 10/4/2016.

- Patient #19's medical record review on 2/7/2017 revealed the patient was admitted on 10/25/2016 and discharged on 10/25/2016 with a diagnosis of Right Carpal Tunnel Syndrome (numbness and tingling in the hand caused by a pinched nerve in the wrist). Physician Staff Q placed 11 verbal orders on 10/25/2016 and Physician's Assistant Staff R placed 9 verbal orders on 11/8/2017.

- Patient #20's medical record review on 2/7/2017 revealed the patient was admitted on 11/17/2016 and discharged on 11/18/2016 with a diagnosis of Stress Urinary Incontinence (loss of control of the bladder). Physician Staff D placed 15 verbal orders on 11/17/2016.

Chief Nursing officer Staff FF interviewed on 2/8/2017 at 4:45 PM indicated medical staff reviews all policies. Staff F revealed that in the pre and post-operative areas the physicians would give verbal orders to nursing staff. Staff F reported often times if the patient is an inpatient the physicians, physician's assistants are out of the building and the nurses have to call them to get orders.

Policy titled Verbal and Telephone Orders reviewed on 2/8/2017 at 3:30 PM directed "...Verbal communication of prescription or medication orders and test results is limited to urgent situations in which immediate written or electronic communication is not feasible..."

Based on medical record review, document review, and staff interview the hospital failed to ensure the provider signed, dated, and timed verbal/telephone orders promptly for 14 of 20 medical records reviewed (Patient #'s 1-4, 7-10, 12, 13, 15, and 17-19). This deficient practice had the potential to place patients at risk for complications and medical errors

Findings include:

- Patient #1's medical record review on 2/7/2017 revealed the patient was admitted on 3/6/2016 and discharged on 3/11/2016 with a diagnosis of Stenosis (narrowing of open spaces in the lower spine and Myelopathy (a nervous system disorder that affects the spinal cord). Physician Staff G placed 15 verbal orders on 3/7/2016, 3 on 3/8/2016. Physician's Staff K placed 37 verbal orders on 3/7/2016, 3 on 3/9/2016, 2 on 3/10/2016, and 1 on 3/11/2016. The orders were signed on 4/12/2016 (32 days after discharge).

- Patient #2's medical record review on 2/7/2017 revealed the patient was admitted on 6/28/2016 and discharged on 6/28/2016 with a diagnosis of Poor Wound Healing. Physician Staff F placed 16 verbal orders on 6/28/2016 and Advanced Practice Registered Nurse (APRN) Staff J placed 26 verbal orders on 6/28/2016. The orders were signed on 7/7/2016 (9 days after discharge).

- Patient #3's medical record review on 2/7/2017 revealed the patient was admitted on 1/16/2017 and discharged on 1/16/2017 with a diagnosis of Stress urinary incontinence (loss of bladder control). Physician Staff D placed 15 verbal orders on 1/16/2017. The orders remained unsigned as of survey date 2/7/2017 (22 days after discharge).

- Patient #4's medical record reviewed on 2/7/2017 revealed the patient was admitted on 9/7/2016 and discharged on 9/7/2016 with a diagnosis of Post laminectomy Syndrome (failed back surgery syndrome). Physician Staff S placed 16 verbal orders on 9/7/2016 and signed them on 9/21/2016 (14 days after discharge). Physician Staff N placed 11 verbal orders on 9/7/2016 and signed them on 9/29/2016 (22 days after discharge). Physician Staff L placed 1 verbal order on 9/7/2016 the order remains unsigned as of survey date 2/7/2016 (153 days after discharge).

- Patient #7's medical record review on 2/7/2017 revealed the patient was admitted on 3/17/2016 and discharged on 3/19/2016 with a diagnosis of Bilateral PARS Defect (a spinal disorder in which a bone slips forward onto the bone below). Physician Staff F placed 15 verbal orders on 3/17/2016, Physician Staff L placed 1 verbal order, and Physician's Assistant Staff J placed 32 verbal orders on 3/17/2016 and 3 verbal orders on 3/18/2016. The orders were signed on 3/24/2016 (5 days after discharge).

- Patient #8's medical record review on 2/7/2017 revealed the patient was admitted on 3/30/2016 and discharged on 4/2/2016 with a diagnosis of Stenosis and Anterolisthesis (a condition in the upper spine where the area in front of the vertebrae slips forward). Physician Staff G placed 14 verbal orders on 3/30/2016, 5 verbal order on 3/31/2016, and 2 verbal orders on 4/1/2016, Physician's Assistant Staff K placed 36 verbal orders on 3/30/2016 and 5 verbal orders on 4/1/2016. Physician Staff M placed 1 verbal order on 3/31/2016. The orders were signed on 4/12/2016 (10 days after discharge).

- Patient #9's medical record review on 2/7/2017 revealed the patient was admitted on 5/16/2016 and discharged on 5/18/2016 with a diagnosis of Right Hip Arthroplasty (surgical reconstruction or replacement of a joint). Physician Staff E placed 17 verbal orders on 5/16/2016 and Physician's Assistant Staff T placed 59 verbal orders on 5/17/2016 and 1 verbal order on 5/18/2016. Staff T ' s orders were signed on 6/6/2016 (18 days after discharge).

- Patient #10's medical record review on 2/7/2017 revealed the patient was admitted on 5/20/2016 and discharged on 5/20/2016 with a diagnosis of a Post of Hematoma (swollen collection of clotted blood). Physician Staff B placed 21 verbal orders on 5/20/2016 the orders were signed on 5/27/2016 (7 days after discharge). Physician's Assistant Staff M placed 1 verbal order on 5/20/2016 and 1 on 5/21/2016, and Physician Staff L placed 1 verbal order on 5/20/2016 and signed the orders on 1/11/2017 (236 days after discharge).

- Patient # 12's medical record review on 2/7/2017 revealed the patient was admitted on 7/14/2016 and discharged on 7/16/2016 with a diagnosis of Spondylolisthesis (a spinal disorder in which a bone slips forward onto the bone below it). Physician Staff O placed 11 verbal orders on 7/14/2016, 2 verbal orders on and 7/15/2016. ARNP Staff U placed 18 verbal orders on 7/14/2016, 8 verbal orders on 7/15/2016, and 2 verbal orders on 7/16/2015. Physician's Assistant. Staff V placed 1 verbal order on 7/16/2016 the order remains unsigned as of the date of the survey 2/7/2016 (206 days).

- Patient #13's medical record review on 2/7/2017 revealed the patient was admitted on 8/23/2016 and discharged on 8/24/2016 with a diagnosis of Herniated Disc (a problem with the rubbery disc between the spinal bones). Physician Staff B placed 15 verbal orders on 8/23/2016 and Physician's Assistant Staff I placed 2 verbal orders on 8/24/2016. The orders were signed on 10/6/2016 (43 day after discharge)

- Patient #15's medical record review on 2/7/2017 revealed the patient was admitted on 5/4/2016 and discharged on 5/6/2016 with a diagnosis of Left Knee Unilateral Primary Osteoarthritis (a non-inflammatory disease of the knee joint). Physician Staff FC placed 76 verbal orders on 5/4/2016, 2 verbal orders on 5/5/2016, and 5 on 5/6/2016. One order remained unsigned until 5/12/2016 (6 days after discharge).

- Patient #17's medical record review on 2/7/2017 revealed the patient was admitted on 9/7/2016 and discharged on 9/8/2016 with a diagnosis of Herniated Nucleus Pulposus (a problem with the rubbery disc between the spinal bones).Physician Staff H placed 15 verbal orders on 9/7/2016 and 1 verbal order on 9/8/2017. Physician's Assistant Staff W placed 34 verbal orders on 97/2016 and 1 verbal order on 9/8/2016. The orders were signed on 11/16/2016 (69 days after discharge).

- Patient # 18's medical record review on 2/7/2017 revealed the patient was admitted on 10/4/2016 and discharged on 10/4/2016 with a diagnosis of Retained Drain Fragment (a piece of medical equipment designed to remove fluid from the inside of a patient's body). Physician Staff H placed 15 verbal orders on 10/4/2016 and Physician ' s Assistant Staff W placed 25 verbal orders on 10/4/2016. The orders were signed on 11/16/2016 (43 days after discharge).

- Patient #19's medical record review on 2/7/2017 revealed the patient was admitted on 10/25/2016 and discharged on 10/25/2016 with a diagnosis of Right Carpal Tunnel Syndrome (numbness and tingling in the hand caused by a pinched nerve in the wrist). Physician Staff Q placed 11 verbal orders on 10/25/2016 and Physician's Assistant Staff R placed 9 verbal orders on 11/8/2017. The orders were signed on 11/8/2016 (14 days after discharge).

Medical Records Staff EE interviewed on 2/7/2016 at 3:00 PM indicated it was hard to get physicians to sign their documentation.

Policy titled Verbal and Telephone Orders reviewed on 2/8/2017 at 3:30 PM directed "...These orders shall be authenticated by the prescribing or covering practitioner within 72 hours of the patient's discharge or 30 days, whichever comes first ..."

Based on document review, medical record review and staff interview, the hospital failed to ensure patients had a comprehensive medical history and physical examination less than 30 days prior to surgery for 2 of 20 medical records reviewed (Patient #'s 5 and 20). The failure to ensure patients have a signed and dated medical history and physical examination places the patients at risk for complications and medical errors.

Findings include:

- Patient #5's medical record review on 2/7/2017 revealed the patient was admitted on 7/11/2016 and discharged on 7/12/2016 with a diagnosis of Post Laminectomy Syndrome (failed back surgery syndrome). The medical record lacked evidence of a history and physical completed within 30 days of surgery.

- Patient #20's medical record review on 2/7/2017 revealed the patient was admitted on 11/17/2016 and discharged on 11/18/2016 with a diagnosis of Stress Urinary Incontinence (loss of control of the bladder). The medical record lacked evidence of a history and physical completed within 30 days of surgery.

Medical Records Staff EE interviewed on 2/7/2017 at 2:00 PM indicated they and another person go through the medical records to ensure everything is accurate and was not aware of anything missing in any of the records.

Policy titled History and Physical reviewed on 2/8/2017 at 5:15 PM directed "...When the medical history and physical examination are completed within 30 days before an admission, an updated medical record entry must be completed and documented in the patients' medical record within 24 hours after admission or registration...and...This update must take place prior to surgery or a procedure requiring anesthesia services. The update note must document an examination for any changes in the patient's condition since the patients H&P was performed that might be significant for the planned course of treatment..."

Based on medical record review, document review, and staff interview the hospital failed to ensure 9 of 20 medical records were completed within 30 days of the patient's discharge (Patient #'s 1, 4, 7, 8, 10, 12, 13, 17, and 18). This deficient practice had the practice had the potential for inadequate follow-up care.

Findings include:

- Patient #1's medical record review on 2/7/2017 revealed the patient was admitted on 3/6/2016 and discharged on 3/11/2016 with a diagnosis of Stenosis (narrowing of open spaces in the lower spine and Myelopathy (a nervous system disorder that affects the spinal cord). The orders documented during this admission were signed on 4/12/2016 (32 days after discharge).

- Patient #4's medical record reviewed on 2/7/2017 revealed the patient was admitted on 9/7/2016 and discharged on 9/7/2016 with a diagnosis of Post laminectomy Syndrome (failed back surgery syndrome). Physician Staff L placed 1 verbal order on 9/7/2016 the order remains unsigned as of survey date 2/7/2016 (153 days after discharge).

- Patient #7's medical record review on 2/7/2017 revealed the patient was admitted on 3/17/2016 and discharged on 3/19/2016 with a diagnosis of Bilateral PARS Defect (a spinal disorder in which a bone slips forward onto the bone below). The discharge summary was signed on 5/11/2016 (53 days after discharge).

- Patient #8's medical record review on 2/7/2017 revealed the patient was admitted on 3/30/2016 and discharged on 4/2/2016 with a diagnosis of Stenosis and Anterolisthesis (a condition in the upper spine where the area in front of the vertebrae slips forward). The history and physical was signed on 5/24/2016 (52 days after discharge).

- Patient #10's medical record review on 2/7/2017 revealed the patient was admitted on 5/20/2016 and discharged on 5/20/2016 with a diagnosis of a Post of Hematoma (swollen collection of clotted blood). An order placed during this admission was signed on 1/11/2017 (236 days after discharge).

- Patient # 12's medical record review on 2/7/2017 revealed the patient was admitted on 7/14/2016 and discharged on 7/16/2016 with a diagnosis of Spondylolisthesis (a spinal disorder in which a bone slips forward onto the bone below it). An order remains unsigned as of the date of the survey 2/7/2016 (206 days).

- Patient #13's medical record review on 2/7/2017 revealed the patient was admitted on 8/23/2016 and discharged on 8/24/2016 with a diagnosis of Herniated Disc (a problem with the rubbery disc between the spinal bones). The orders documented during this admission were signed on 10/6/2016 (43 days after discharge). The discharge summary was signed on 10/28/2016 (65 days after discharge).

- Patient #17's medical record review on 2/7/2017 revealed the patient was admitted on 9/7/2016 and discharged on 9/8/2016 with a diagnosis of Herniated Nucleus Pulposus (a problem with the rubbery disc between the spinal bones).The verbal orders documented during this admission were signed on 11/16/2016 (69 days after discharge). The discharge summary was dictated on 9/8/2016 and signed on 12/20/2016 (103 days after discharge).

- Patient # 18's medical record review on 2/7/2017 revealed the patient was admitted on 10/4/2016 and discharged on 10/4/2016 with a diagnosis of Retained Drain Fragment (a piece of medical equipment designed to remove fluid from the inside of a patient's body). The orders were signed on 11/16/2016 (43 days after discharge). The discharge summary was signed on 11/16/2016 (43 days after discharge).

Medical Records Staff EE interviewed on 2/9/2016 at 9:40 AM revealed documentation they provided to medical staff notifying them of a pending suspension of privileges for delinquent medical records. Staff EE indicated most of the physicians are held accountable and the suspension is upheld, but not all of them.

Policy titled Delinquent Records & Suspension Policy reviewed on 2/9/2017 at 9:30 AM directed "... All medical records are to be completed within 30 days of discharge..."

Based on observation, interview and policy and procedure review the hospital failed to ensure 1 multi-dose vial of insulin was dated upon opening. Failure of the facility to date an opened multi-dose vial of medication puts all patients at risk for receiving medications that are ineffective and unsafe to use. The facility also failed to label pre-drawn medications used in surgery. Failure to label pre-drawn medications puts all patients at risk for an allergic reaction, receiving the wrong medication and medications errors with potential for fatal outcomes.

Findings include:

- Observation on 2/6/17 at 1:34 PM revealed the pre-operation nursing area medication refrigerator had one multi-dose vial of Novolin R (a medication for diabetics) opened and a sticker to document date opened and date to discard the medications with no dates on the sticker.

Interview on 2/6/17 at 1:34 PM, Registered Nurse (RN) Staff NN verified the multi-dose medication with a blank sticker on it. Staff NN stated the staff who opened the vial must have forgot to date when they opened it and when to discard it in 28 days. Staff NN discarded the vial.

Policy and Procedure review on 2/6/17 revealed policy "Sterile Medication Preparation" states...once opened, single-dose and multi-dose containers will be discarded after the following time period, unless otherwise specified by the manufacturer: multiple dose vials 28 days.


- Observation on 2/8/17 at 12:22 PM revealed, Certified Registered Nurse Anesthetists (CRNA) (a master's prepared advanced practice nurse who provide anesthetics (a substance that induces insensitivity to pain) to patients in every practice setting, and for every type of surgery or procedure) Staff YY placed 3 pre-filled syringes in the anesthesia cart in operating room (OR) 1 and left the room. Staff BB was present in the room and opened the drawer which revealed one of the syringes was not labeled.

Interview on 2/8/17 at 12:23 PM, CRNA Staff YY verified the 3 syringes that were placed in the anesthesia cart in OR 1. Staff YY stated the syringes were drawn up for a patient scheduled in OR 6 earlier that morning and they were transferred to OR 5. Staff YY placed the syringes in OR 1 for use with the patient scheduled at the end of the day. Staff YY stated everyone knows that this unlabeled syringe contains Propofol (a medication to promote relaxation and sleepiness before and during surgery and other medical procedures) by its color. Staff YY stated they syringe should have been labeled and was missed.

Interview on 2/8/17 at 1:33 PM, Medical Director of Anesthesia Staff L stated the syringes are pre-drawn by the CRNA's when they are bringing the patient from the pre-op area to the operating room. All syringes are to be properly labeled upon drawing up the medication.

- Policy and Procedure review on 2/8/17 revealed policy "Sterile Medication Preparation" states...labels should be affixed to containers so that they can be read when the container is hanging.

Improving Patient Safety, 2006 JCAHO National Patient Safety Goal 3D states...label all medications, medications containers(e.g., syringes, medicine cups, basins) or other solutions on and off the sterile field in perioperative and other procedural settings...the new National Patient Safety Goal (NPSG) is a risk reduction activity that is consistent with safe medication practices and addresses a recognized risk point in the safe administration of medications in any procedural setting (e.g., OR, Cath Lab, bedside procedures).Errors have resulted from medications and solutions removed from their original containers and placed into unlabeled containers...a label will be applied when any medication or solution is transferred from the original packing to another container unless the medication or solution is administered and/or disposed of immediately by the person preparing that medication or solution.

Based on observation, interview and policy and procedure review the hospital failed to ensure expired medical supplies were removed and discarded in the pre-admission anesthesia cart, the crash cart in the post-operative area, the post-operative nursing area, the pre-operative nursing supply area, the main inpatient medication room, Operating Rooms (ORs) 1 - 6 and central supply. Failure to remove and discard expired supplies put all patients at risk for receiving care with ineffective and unsafe medical equipment.

Findings include:

Observation on 2/6/17 at 12:26 PM revealed the pre-admission anesthesia cart with the following expired supplies:
- Spinal needles 22g x 5" (needle width and length) 2 expired on 2/16
- Spinal needle 18G x 3½" 1 expired on 3/16
- Spinal needle 20g x 3 ½" 1 expired on 1/17
- Spinal needle 25g x 3" 10 expired on 10/16
- Tracheostomy Tube Cuffed (a curved tube that is inserted into a hole in the neck and windpipe (trachea)) 1 expired on 10/16
- Gauze Sponge 1 expired on 10/16
- Probe cover kit with gel (used for routine puncture and drainage procedures) 3 expired on 6/16

Interview on 2/6/17 at 12:37 PM, Anesthesia Director, Staff verified the outdated supplies in the pre-admission anesthesia cart. Staff stated they do not use these supplies anymore and will remove them now.


Observation on 2/6/17 at 12:40 PM revealed the crash cart in the post-operation area with the following expired supplies:
- Tracheostomy Tube Cuffed 1 expired on 10/16
- Intravenous (IV) Extension Tube with 3 way stopcock (an extension tube placed in a vein with a valve that regulates the flow of fluid through a tube) 2 expired on 10/16

Interview on 2/6/17 at 12:51 PM, Registered Nurse (RN) Staff verified the expired supplies, removed and discarded them.


Observation on 2/6/17 at 12:53 PM revealed the post-operation nursing area with the following expired supplies:
- Medipore plus pad wound dressing (an dressing used over wounds with a special tape to make the adhesive firmer) 4 expired on 11/15
- Medipore plus pad wound dressing 12 expired 9/16
- 1,000 milliliter (a metric measurement of a thousandth of a liter (a liter is equivalent to 4 cups)) bottle of sterile water 12 expired on 9/16
- Surgical needle 22g x 1" 5 expired on 12/16
- Purple top lab tube 1 expired on 5/13
- Green top lab tube 1 expired on 8/13

Interview on 2/6/17 at 1:09 PM, RN Staff verified the expired supplies, removed and discarded them.


Observation on 2/6/17 revealed the pre-operation nursing supply area with the following expired supply:
- Red top lab tube 1 expired on 5/16.

Interview on 2/6/17 at 13:34 PM, RN Staff verified the expired lab tube, removed and discarded it.


Observation on 2/6/17 at 2:20 PM revealed the main inpatient medication room in the hospital with the following expired supply:
- IV extension kit with 3 way stopcock 1 expired 9/15

Interview on 2/6/17 at 2:20 PM, RN Staff verified the expired supply, removed and discarded it.


Observation on 2/7/17 at 9:18 AM revealed operating room (OR) 3 with the following expired supplies:
- Surgical needle 18g x 1 1/16th 2 expired on 3/15, 1 expired on 9/15, 2 expired on 10/15, 3 expired on 6/16 and 2 expired on 10/16.
- Angiocath needle 14g x 3.25 " (a needle used to give blood, medicine or fluids to a patient intravenously (in a vein) 2 expired on 11/15 and 1 expired on 3/16


Observation on 2/7/17 at 9:23 AM revealed OR 6 with the following expired supplies:
- Angiocath needles 18g x 1 1/16th" 6 expired on 9/16
- Angiocath needles 20g x 1" 2 expired on 9/16
- Angiocath needles 24g x 3/4th" 2 expired on 3/13


Observation on 2/7/17 at 9:27 AM revealed OR 5 with the following expired supplies:
- Spinal needle 25g x 3" 5 expired on 10/16 and 4 expired on 12/16
- Spinal needle 22g x 3 ½ "1 expired on 1/13
- Angiocath needle 14g x 3.25 " 1 expired on 12/16
- Angiocath needle 18g x 1 1/16th" 1 expired on 10/16, 1 expired on 11/16 and 1 expired on 12/16
- Laryngeal mask airway (a medical device that keeps a patient's airway open during anesthesia (medication used in surgery) or unconsciousness) 1 expired on 5/16

Observation on 2/7/17 at 9:32 AM revealed OR 4 with the following expired supplies:
- blue top lab tube 1 expired on 3/15
- purple top lab tube 1 expired on 12/15
- green top lab tube 2 expired on 2/15 and 2 expired on 9/15
- pink top lab tube 2 expired on 10/15
- angiocath needle 14g x 3 1/4th" 1 expired on 11/15
- angiocath needle 20g x 1" 1 expired on 9/16
- angiocath needle 18g x 1 1/16th" 1 expired on 8/16, and 2 expired on 10/16
- arterial blood sample kit (used to perform a test of the blood in the arteries to get an accurate measurement of oxygen and carbon dioxide levels) 1 expired on 5/14


Observation on 2/7/17 at 11:21 AM revealed OR 1 with the following expired supplies:
- green top lab tube1 expired on 4/14
- IV port clave (allows access to attach a syringe for medications to be given through an IV) 1 expired on 2/16
- IV needle 20g x 1" 1 expired on 9/16
- angiocath needle 14g x 3 1/4th" 1 expired on 3/16
- IV needle 18g x 1 1/16th" 1 expired on 5/16, 2 expired on 8/16, 2 expired on 9/16 and 4 expired on 10/16


Observation on 2/7/17 at 11:25 AM revealed OR 2 with the following expired supplies:
- Angiocath needle 14g x 3 1/4th" 1 expired on 12/16
- Angiocath needle 24g x 3/4th" 1 expired on 5/12
- Angiocath needle 18g x 1 1/16th" 1 expired on 9/16 and 2 expired on 11/16
- blue top lab tube 1 expired on 3/15 and 1 expired on 5/15
- green top lab tube 3 expired on 7/15, 2 expired on 2/15 and 2 expired on 7/14
- vacutainer kit (a kit with a lab tube to collect blood) 1 expired on 7/14
- 4 way stopcock 1 expired on 9/13
- IV port clave 1 expired on 2/16

Interview on 2/7/17 at 9:21 AM and again at 11:25 AM, OR Manager Staff DD verified all the expired medications from OR 1, 2, 3, 4, 5, and 6. Staff DD stated the anesthesiologist do not use these drawers in the anesthesia cart they now use the supply cart next to it and it is stocked by the staff. These drawers have not been used in a long time. Staff DD removed the supplies and discarded them immediately.


Observation on 2/7/17 at 12:59 PM revealed the central supply room with the following expired supply:
- Providone Iodine 10% 1 bottle expired on 12/16

Interview on 2/7/17 at 12:59 PM, Central Supply Tech Staff TT verified the expired supply and discarded it immediately.


Interview on 2/7/17 at 12:07 PM, Staff SS stated an e-mail was sent to all directors that beginning February 2017 a new monthly crash cart checklist would be initiated. The purpose was to keep all the crash carts organized in a uniformed fashion per the Medical Anesthesiologist and to prevent expired equipment from being used and to prevent waste by circulating out equipment that is expiring soon for more immediate use.


Policy and Procedure review on 2/7/17 at 10:39 AM revealed policy "Safe Medical Device Practices" states...medical device: the food and drug administration (FDA) defines a medical device as any instrument, apparatus, machine, or other article used to prevent, diagnose, mitigate or treat a disease, or to affect the structure or function of the body excluding medications. A medical device, therefore, is broadly defined and ranges from gauze sponges to implanted devices, to mechanical and electronic equipment ...inspection of the device, as applicable: check expiration or by-use-date.

Based on observation, interview and policy and procedure review the hospital failed to ensure there was a system for controlling infections and communicable diseases as evidenced by: staff failing to disinfect the rubber top of a medication vial prior to drawing up a medication (Student Staff ZZ and RN Staff AAA); staff failing to ensure proper hand hygiene during a dressing change (Student Staff QQ and RN Staff RR) and during an IV (intravenous-in the vein catheter placement) (RN Staff CC); staff failing to ensure surgical masks were removed when leaving the operating room (OR) (Anesthesia Staff MM); staff failing to ensure a proper and complete terminal cleaning in 1 of 6 operating rooms observed (Cleaning Staff PP); staff failing to ensure proper personnel protective equipment (PPE) was worn in OR 5 for 4 of 7 staff members observed (Staff BBB, Y, Z, and BB); the facility failing to ensure all surfaces in the Operating Room (OR) were cleanable (table in OR 1); and by staff failing to ensure food items in the kitchen were discarded after the expiration date, kitchen equipment was properly cleaned, food was secured in closed containers, a backflow was placed in the kitchen sinks, and a broken light cover in the refrigerator was replaced.

Failure to ensure the staff followed acceptable infection control standards of practice placed all patients at risk for exposure to blood-borne pathogens, infectious diseases, cross-contamination, and food-borne illnesses.

Findings include:

- Observation on 2/7/17 at 8:46 AM revealed Nursing Student Staff ZZ opening a vial of Reglan (a medication used for nausea). Staff ZZ flipped off the top to the vial and then proceeded to inject the sterile needle to draw out the medication. Staff ZZ failed to disinfect the rubber top to the vial prior to drawing up the medication. RN Staff AAA was mentoring the student and failed to instruct Staff ZZ to disinfect the rubber top of the vial.

Interview on 2/7/17 at 8:47 AM, RN Staff AAA stated they missed the step of disinfecting the rubber top to the medication vial and was aware it should have been done.

- Policy and Procedure review on 2/7/17 at 12:12 PM revealed policy "Administration of Medication" states...All personnel administering medications will demonstrate competency prior to administering approved medications...nursing students may administer medications under the direct supervision of their instructor or designated licensed personnel ...the stopper will be swabbed with an alcohol pad before each puncture.

- Observation on 2/7/17 at 1:05 PM revealed Nursing Student Staff QQ and RN Staff RR performing a dressing change to a patient. Staff QQ and Staff RR had several glove changes from changing the bloody soiled dressing to clean and applying a new dressing and each time failed to perform hand hygiene in between glove changes.

Interview on 2/7/17 at 1:17 PM, Staff QQ and Staff RR verified hand hygiene was not performed in between glove changes and should have been done. Staff RR verified they would need to wash hand in between glove changes as there is no hand sanitizer in the rooms.

- Observation on 2/7/17 at 9:40 AM, Registered Nurse Staff CC at patient # 21 bedside. Staff CC grabbed the IV stylet (needle that is inserted into a vein) package which immediately dropped on the floor. Staff CC picked up the contaminated IV stylet package from the floor and placed it on patient # 21's bed. Staff GG retrieved a new IV stylet for Staff CC. Staff CC removed their gloves and immediately put new gloves on to continue with the IV insertion on patient #21. Staff CC did not perform hand hygiene after taking contaminated gloves off.

Interview on 2/7/17 at 10:00 AM, Registered Nurse Staff CC acknowledged they should have performed hand hygiene after removing gloves.

- Policy and Procedure review on 2/7/17 revealed policy "Hand Hygiene" stated...hand hygiene remains the single most important means of preventing hospital acquired infections (HAIs). HAIs may be caused from the patient's own flora, or by organisms patients acquire from the hospital environment. Organisms transmitted from the hands of hospital personnel may cause a variety of infections in hospitalized patients; therefore, it is the duty of all healthcare workers to decrease the risks of contamination to patients through practicing proper hand hygiene...decontaminate hands if moving from a contaminated body site to a clean body site during patient care...decontaminate hands after removing gloves.

- Observation on 2/6/17 at 1:26 PM revealed Anesthesiologist Staff MM walking into the pre-operative (pre-op)area wearing a surgical mask hanging around the neck, speaking with a patient and then proceeding to leave the pre-op area.

Interview on 2/6/17 at 1:29 PM, Staff MM verified the surgical mask was from the OR and proceeded to remove the surgical mask.

- Policy and Procedure review on 2/7/17 revealed policy "Surgery Dress Code" states...to establish a surgical dress code that promotes and ensures a high-level of cleanliness and hygiene within the surgical environment and provides a barrier to contamination between patient and personnel...a mask should cover both mouth and nose and be secured in a manner that prevents venting. Masks are to be changed between patients and should be carefully removed and discarded after use by handling only the ties. They should not be saved by hanging around the neck or tucking into a pocket for future use and are to be removed before leaving the OR area.

- Observation on 2/6/17 at 3:26 PM revealed contracted cleaning services Staff PP performing a terminal clean for OR room 1. Staff PP failed to clean all the wall areas. Missing wall areas include: the bottom half of all 4 walls, the area where x-rays are placed for reading, and an air vent and large silver area on the south east wall. The top half of the walls were cleaned and water from the cleaning fell on several pieces of OR equipment placed around the perimeter of all 4 walls. High areas on the OR lights, silver equipment storage area and door were cleaned with a used feather duster. The attachment hose on a "bear hug" machine (used to inflate plastic cuffs to the lower legs) fell on the dirty floor two times after it was cleaned and they were never re-cleaned. ALL surgical equipment in the entire OR were cleaned with a wet rag in an appropriate Virex solution were disinfected and cleaned and then immediately dried with a towel. The drying towel fell onto the dirty floor after the first piece of equipment was cleaned and used to dry every piece of equipment in the OR. A very large plastic floor mat was lifted off the floor folded in half with the dirty side out and placed between the anesthesia medication and supply carts. The surgical floor failed to be swept and was cleaned by squeezing out Virex on the floor in various places and mopped. Several pieces of equipment were moved away from the wall and mopped under, but most of the surgical equipment was just mopped around.

Interview on 2/6/17 at 4:32 PM, Contracted Housekeeping Staff PP stated they have been cleaning 4 of the OR rooms every night for the last 4 years. Staff PP verified all the wall areas were not cleaned, equipment was not moved away from the walls prior to cleaning, the high areas were fine to be cleaned with a feather duster, the large plastic dirty rug was placed between clean surgical equipment, the floor was not swept before mopping and all equipment was not moved when mopping the floor. Staff PP was not aware that the "bear hug" hose had fallen onto the dirty floor twice and that the rag used to dry all the equipment fell on to the floor. Staff PP stated they were told to dry the equipment immediately after wiping down to avoid any water spots.

- Policy and Procedure review on 2/7/17 revealed policy "OR Terminal Cleaning and Disinfection" stated...terminal cleaning and disinfection of the perioperative environment decreases the number of pathogens and the amount of dust and debris. This guideline is for a standardized daily terminal cleaning and disinfection of the perioperative areas...the semi-restricted and restricted areas will be terminally cleaned on a schedule daily basis by specially trained housekeeping personnel...terminal cleaning: all floors in perioperative areas... shall be terminal cleaned with either wet vacuum or a single-use mop and disinfectant. The floor should be wet with the disinfectant for the time indicated on the manufacturer's instructions. Cleaning should progress from the cleanest to the dirtiest areas of the floor. Entire floor surfaces should be disinfected, including under OR beds and mobile furniture.*Terminal cleaning of OR should include all exposed surfaces, high touch objects, including wheels and casters.

- Observation on 2/7/17 at 2:00 PM, Registered Nurse Staff BBB observed in the Operating Room failed to follow hospital policy to ensure all hair is covered under the surgical cap.

- Observation on 2/7/17 at 2:00 PM, CRNA (Certified Registered Nurse Aesthesis) student Staff Y in the Operating Room failed to follow hospital policy to ensure all hair is covered under the surgical cap.

Interview on 2/7/17 at 3:55 PM, CRNA Student Staff Y, Surveyor explained to Staff Y it is the hospital policy to have all hair covered in the surgical cap. Staff Y felt the back of her neck and felt the hair outside the surgical cap and did not realize all her hair was not cover.

- Observation on 2/7/17 at 2:30 PM, Radiology Technician Staff Z in the Operating Room failed to follow hospital policy to ensure all hair is covered under the surgical cap.

Interview on 2/8/17 at 10:15 AM, Radiology Technician Staff Z, Surveyor explained to Staff Z when they were in the Operating Room yesterday their hair in the back of their neck was not entirely covered inside the surgical cap.

- Observation on 2/7/17 at 3:00 PM, Registered Nurse Staff BB observed in the Operating Room failed to follow hospital policy to ensure all hair is covered under the provided surgical cap.

Interview on 2/7/17 at 4:30 PM, Quality and Risk Manager Staff A, Surveyor explained to them while observing the staff in the Operating Room during patient #21's surgery their staff members (Staff BBB, Y, Z, and BB) did not entirely cover their hair inside the surgical cap. Staff A stated it is their policy to have all hair tucked in surgical cap in the Operating suite.

- Policy titled "Surgery Dress Code" reviewed on 2/8/2017 directed staff "...Personnel should cover head and facial hair, including sideburns and necklines when in semi-restricted and restricted areas of the surgical suite..."

- Observation on 2/8/17 at 12:25 PM revealed a pad on the bed in OR 1 had several cracks on it. Failure to replace this pad makes the surface non-cleanable and prime for containing blood borne pathogens and bacteria.

Interview on 2/8/17 at 12:34 PM, OR Director Staff DD stated the pads on the beds are routinely checked and this one had been missed. The pads are easily replaceable and will be changed.

- Policy and Procedure review on 2/9/17 revealed policy "High-Level Disinfection" stated ...inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization...equipment that no longer functions as intended or cannot be properly cleaned, disinfected or sterilized will be discarded or repaired according to manufacturer's recommendations.


Observation on 2/7/17 at 1:43 PM revealed the kitchen failed to ensure the following items were free from contamination:
- 1 bag of pancake mix that was opened in a cupboard
- 1 bottle of lemon juice (32 ounces) that was 3/4th empty sitting on a shelf that had not been refrigerated
- 8 packages of turkey in the freezer that expired 2/2/17 (5 days ago)
- 4 containers of peanut butter (6 pounds each) that expired 8/5/16
- 1 box of raisins that expired 8/26/16
- Silver storage and cooking tables were not cleaned (a wet rag was taken to the areas and they were able to be cleaned easily)
- Vents to the electric panels in the food storage area were dirty
- The grill and vents above the stove and fryer were greasy
- White build up around the ice machine
- A broken light cover was over the light in the refrigerator
- 3 kitchen sink did not have backflow devices installed

Interview on 2/7/17 at 1:43 PM, Dietary Director Staff UU verified the expired items, broken items, and dirty items during the inspection of the kitchen. Staff UU removed and discarded the expired items, and will call maintenance to clean and fix the broken and dirty items. Staff UU stated they have a small crew of 2 people on the weekends and it is difficult to perform the cleaning on a routine basis. Staff UU stated maintenance is quick to respond to requests.

Interview on 2/7/17 at 2:13 PM, Maintenance Director Staff VV stated the kitchen sinks do not have a backflow system in them and they will address this with the hospital administration for correction.

- Policy and Procedure review on 2/7/17 revealed policy "Food and Supply Storage Procedures" stated...cover, label and date unused portions and open packages. Use the Morrison orange label; complete all sections on the label ...remove from storage any items for which the expiration date has expired.

- Policy and procedure review on 2/9/17 revealed policy "Equipment Sanitation" stated...to ensure proper maintenance of food service equipment to reduce risk of foodborne infection...equipment will be cleaned and sanitized as recommended by manufacturers and applicable rules and regulations as outlined by the Authorities Having Jurisdiction (AHJ) ...clean food carts daily or more often if needed.