HospitalInspections.org

Based on document review, the facility does not ensure all personnel meet all applicable personnel health requirements in accordance with State law for 8 of 11 clinical staff.
(Staff # 7, 9, 10, 13, 14, 16, 17, and 18).

Findings Include:

Review on 7/14/11 of personnel/credential files for Staff # 7, 9, 10, and 18 revealed no evidence of immunization against rubella.

Review on 7/14/11 of personnel/credential files for Staff # 7 and 10 revealed no evidence of immunization against measles.

Review on 7/14/11 of personnel/credential files for Staff # 10, 13, 14, 16, and 17 revealed documentation of the testing for the detection of latent tuberculosis infection was not current and/or not performed annually.

Review on 7/14/11 of personnel/credential files for Staff # 7 and 10 revealed no documentation of a current health reassessment.

These findings were verified with Staff #1 and Staff # 23 on 7/14/11.

THIS IS A REPEAT DEFICIENCY.


Based on document review, the facility does not ensure all staff have received training during orientation and ongoing, regarding abuse, neglect, and related reporting requirements in accordance with State law for 11 of 11 clinical staff (Staff #6-10 and 13-18).

Findings Include:

Review on 7/14/11 of policy 4.6 "Child Abuse and Maltreatment" last revised 10/10 revealed the hospital case manager will provide orientation and continuing education inservices to nursing, medical and other appropriate hospital personnel in collaboration with the Chautauqua County Protection Workers.

Review on 7/14/11 of credential/personnel files for Staff # 6-10 and 13-18 revealed no evidence of training/education related to abuse and neglect protocols and reporting requirements.

This finding was verified with Staff #1 and Staff #23 on 7/14/11.

Based on document review, the facility does not ensure staff receive education on advance directive requirements, protocols and/or policies for 11 of 11 clinical staff members
(Staff # 6-10 and 13-18).

Findings Include:

Review on 7/14/11 of policy #20.03 "Advance Directives" last revised 10/10 revealed the facility's policies, mission and value statement regarding advance directives and withholding life-sustaining measures will be provided to the medical, allied health professionals and hospital staff on a periodic basis and as necessary. Information will be provided through an inservice format as well as newsletters, memorandums, orientation processes, annual personnel reviews and through the Advance Directive Task Force members.

Review on 7/14/11 of the credential/personnel files for Staff # 6-10 and 13-18 revealed no evidence of training/education regarding advance directives.

This finding was verified with Staff #1 and Staff #23 on 7/14/11.

Based on interview, the hospital does not ensure an assignment process for staff to meet emergency patient needs on the medical surgical floor.

Findings Include:

Interview with Staff # 14 on 7/12/11 at 11 AM and Staff # 22 on 7/13/11 at 10 AM revealed a lack of a process or protocol for ensuring additional assistance by staff from other areas of the hospital in the event of a patient emergency (ie. code).

Based on observation the facility did not maintain the medical records storage areas.

Findings Include:

Observation during the tour on 7/14/11 at 12:00 PM revealed improper storage of Medical Records in the Medical Office Building on the hospital campus. Stacked boxes of records were tipped over and spilled on the basement floor.

This finding was verified with Staff # 3 on 7/14/11 .

Based on medical record review, interview and document review, the facility does not ensure patient medications brought from home are verified prior to administration.

Findings Include:

Review of policy 31.50 "Medications from Home, Patient's Own" last revised 10/10 revealed all patient's own medications must be identified prior to administration. If the pharmacy is closed the nurse may call the dispensing pharmacy for identification. If the dispensing pharmacy is unreachable, the physician may either choose to identify the medication or have the medication started in the morning after the pharmacy opens. The pharmacist will note on the patient's profile, "Patient's Own Medication". The same will be noted on the patient's Medication Administration Record.

Interview on 7/13/11 at 11:45 AM with Staff # 14 revealed that physicians write orders to administer patient medications brought from home. The medications are not verified by the physician and or pharmacy before administration.

Review on 7/14/11 of the medical record for Patient #15 revealed the following:
- Physician order dated 4/1/11 revealed "May use med's from home".
- Medication Administration Record dated 4/1/11 through 4/4/11 revealed a note written on the top of the page "May use med's from home."
- There was no documentation in the medical record identifying the name of the medications brought from home for administration and there was no evidence of verification of home medications by either a physician or a pharmacist prior to administration.

Review on 7/14/11 of the medical record for Patient # 16 revealed a physician order dated 3/10/11 "Patient may take own med's from home". There was no evidence in the medical record to indicate the home medications were verified by either a physician or a pharmacist prior to administration.

Interview on 7/14/11 at 10 AM with Staff # 22 revealed a lack of knowledge regarding the facility's policy and procedure 31.50 for verification of home medication prior to administration. Additionally, interview revealed that if a prescription bottle has a drug store label, she administers the medication as ordered without any additional verification by pharmacy or physician.

These findings were verified with Staff #11 on 7/15/11 at 9:30 AM .

Based on observation and document review, the facility does not ensure that outdated drugs and biologicals are not available for patient use.

Findings Include:

Review on 7/15/11 of policy 31.40 " Pharmacy and Clinical Unit Inspections" last revised 10/10 revealed a monthly audit of medications will be performed by pharmacy (PYXIS) and nursing (unit stock) to check expiration dates. Items with impending expiration dates will be removed and replaced.

Observation on 7/13/11 at 10:15 AM in the Emergency Department revealed the following:
- One bottle of Tuberculin vaccine located in the refrigerator at the nursing desk was not dated and/or initialed when opened.
- One open and undated bottle of 2% Pontocaine that expired 1-6-11.

These findings were verified with Staff # 5 on 7/13/11.

Observation on 7/13/11 at 10:56 AM of upper cabinet above the sink in the Radiology Department revealed the following:
- One 0.9% normal saline 250 ml IV bag expired 2/1/2001.
- One 0.9% normal saline 250 ml IV bag expired 1/2003.
- One 0.9% normal saline 1000 ml IV bag expired 9/2004.

These findings were verified with Staff #12 on 7/13/11.

Observation on 7/13/11 at 11:45 AM of the refrigerator located in the Medical/Surgical unit revealed the following:
- One bottle of Humulin R insulin was not dated or initialed when opened.

This finding was verified with Staff # 14 on 7/13/11.

Observation of the Physical Therapy area on 7/13/11 at 9:30 AM revealed the the following:
- One 5 oz bottle of Maalox - Expired 1-09.
- One 100 ml bottle of 0.9% NaCl - open and undated.

These findings were verified with Staff # 24 on 7/13/11.

THIS IS A REPEAT DEFICIENCY.

Based on observation the facility did not maintain the physical plant.

Findings Include:

Observation during the tour on 7/13/11 at 10:30 AM revealed the sheet rock wall surface behind the hopper in the Emergency Department soiled work room was deteriorated.

This finding was verified with Staff # 3 on 7/13/11.

Based on interview the facility did not protect the public water supply.

Findings Include:

Interview with Staff # 3 on 7/15/11 revealed the facility had the backflow prevention device tested in 2009, however the facility did not test the device in 2010.

There is no record to indicate testing of the second backflow prevention device on the facility's sprinkler system was conducted.

THIS IS A REPEAT DEFICIENCY.

Based on observation the facility did not provide infection control standards.

Findings Include:

Observation during the tour on 7/13/11 at 10:15 AM and 7/14/11 at 2:30 PM revealed colonoscopes stored in an open closet in the procedure room. The closet has a collapsible door which was in the open position at time of inspection.

This finding was verified with Staff # 20 on 7/14/11.


Based on observation, the facility did not maintain patient care supplies.

Findings Include:

Observation on 7/13/11 at 10:15 AM in the Emergency Department revealed the following outdated and unusable patient care supplies:
- Two thoracotomy kits located in room #2 had two 22 gauge needles that expired 2/2011 and a 2-0 monofilament that expired 5/2011.
- One 8.0 tracheal tube located on the wall in room #2 near the stretcher was opened and connected to an opened syringe.
- OneYankauer suction catheter located on the wall near the stretcher in room #2 was opened and attached to the suction machine.
- Eight packages of 4-0 Chromic gut sutures - expired 5/11.
- Five packages of 3-0 Chromic gut sutures - expired 3/11.

These findings were verified with Staff # 5 on 7/13/11 .

Observation on 7/13/11 at 10:56 AM of the upper cabinet above the sink in the Radiology Department revealed the following outdated and unusable patient care supplies:
- One Foley catheter tube with bag opened and laying freely in the cabinet.
- One 16 French Foley catheter expired 8/2009.
- One IV set which appeared compromised as evidenced by the yellow discoloration and wear on packaging.
- Two packets of lubricating jelly expired 4/2007.
- One 23 gauge needle expired 4/2009.
- 1 V 4 Quik clip support kit expired 6/1/1999.
- 20 V 4 Quik clip support kit expired 9/1/1999.
- One ultrasound gel pad 2 x 9 cm expired 8/1997.

These findings were verified with Staff #12 on 7/13/11 .

Observation on 7/13/11 at 11:05 AM of the lower cabinet below the sink in the Radiology Department revealed the following expired patient care supplies:
- One 22 gauge needle expired 4/2008.
- One 23 gauge needle expired 1/2009.
- One IV catheter expired 8/2001.

These findings were verified with Staff #12 on 7/13/11 .


Based on observation the facility did not maintain the physical plant.

Findings Include:

Observation during the tour on 7/13/11 between the hours of 9:45 AM and 12:30 PM revealed under sink storage in the following areas:
- Medical Surgical Unit - Nourishment Station.
- Emergency Department.
- Radiology/CT Room.
- Central Processing soiled and clean work rooms.

These findings were verified with Staff # 3 on 7/13/11.


Based on observation and interview the facility did not maintain dietary equipment.

Findings Include:

Observation during the tour on 7/15/11 at 9:15 AM revealed the walk-in freezer was structurally deteriorated, causing condensation to pool on the floor in front of the unit.

This finding was verified with Staff # 3 on 7/15/11.

Based on medical record review and document review, the facility does not ensure the medical staff adhere to the facility's established policies and procedures related to Physician Assistants.

Findings Include:

Review on 7/15/11 of policy 4.13 "Physician Assistants" last revised 10/10 revealed physician assistants will make chart entries on the medical record to reflect the patient's medical condition. Medical orders will be counter signed within 24 hours by the physician.

Review on 7/14/11 of the Emergency Department record for Patient # 12 revealed the physician assistant signature is dated 6/25/11 at 1:15 AM. The supervising physician's co-signature is dated 6/27/11 at 10:30 AM.

Review on 7/14/11 of the Emergency Department record for Patient # 26 revealed the physician assistant signature is dated 6/13/11. The supervising physician's co-signature is dated 6/18/11 at 8:42 AM.

THIS IS A REPEAT DEFICIENCY.