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Based on observation and interview it was determined the Facility did not maintain the condition of the physical environment and equipment to ensure a safe and clean environment. The failed practice had the potential to affect all patients, staff and visitors due to the potential harm to health and safety presented by the observed physical conditions. The Facility had a census of three patients on 07/21/14. The findings follow:

A. On a tour of the Facility on 07/23/14 at 1300 with the Maintenance Technician and Administrative Assistant, the following observations were made:
1) In the CT (computed tomography) Department, a sink counter was observed with missing laminate, with exposed wood and sharp edges.
2) In the Medical Records Department, a section of the ceiling plaster was cracked and crumbling.
3) In Patient Room 104, which was used for storage of patient care equipment, black mold was observed on ceiling tiles.
4) In Patient Room 105, the floor by the window was stained.
5) In Patient Room 106, the floor by the window was stained and the wall under the window was cracked and had peeling paint.
6) In Patient Room 108, in the patient bathroom, the shower head escutcheon ring was rusted and hanging loose from the wall, leaving an opening around the shower head piping. The nurse call button in the bathroom did not function.
7) In Patient Room 110, in the patient bathroom, the shower head escutcheon ring was rusted and hanging loose from the wall, leaving an opening around the shower head piping. The nurse call station in the bathroom was missing a button and did not function.
8) In Patient Room 120, the bathroom nurse call station was missing a button.

B. On a tour of the Facility on 07/24/14 at 0945 with the Maintenance Technician and Administrative Assistant, the following observations were made in the Emergency Department:
1) In Exam Room #1, the wall was damaged with scratches and gouges.
2) In Exam Room #2, the wall was damaged with scratches and gouges.
3) The fire door located at the Emergency Department was damaged on the door edge, with jagged edges and exposed wood.
C. The Maintenance Technician and Administrative Assistant verified each observation during the tour.

Based on observation, review of policy and interview, the Facility failed to ensure outdated medications were not available for patient use in one (Inpatient Wing) of two (Inpatient Wing and Emergency Department) areas toured. By having expired medications available for patient use, the Facility could not ensure the safety or integrity of the medication dispensed. The failed practice had the likelihood to affect all patients who received medication. Findings follow:

A. During a tour of the Facility on 07/21/14 between 1316 and 1520, the following outdated medications were observed:
1) Inpatient Wing Medication Room:
a) 21 Famotadine for Injection 20 mg (milligram)/2 ml (milliliter) expired 04/14;
b) 2 Dextrose 5% in ½ Normal Saline for injection 1000ml expired 06/14;
c) 1 Lactated Ringers 500 ml for injection expired 07/13;
d) 1 Betadine Solution 120 ml for topical use expired 09/12; and
e) 1 Aspirin 325 mg tablet expired 01/14.
2) Inpatient Wing Crash Cart:
a) 2 Nitroglycerin 5% Dextrose 500 ml for injection expired 04/14; and
b) 4 Normal Saline flush for injection expired 03/14.

B. Review of Pharmacy policy titled "Expired Medications" stated "Routine inspections of all medication storage areas are performed on a monthly basis by the pharmacist or pharmacy technician and expired and outdated medications are pulled...".
C. Findings were verified, through interview, at the time of observation on 07/21/14, with the Chief Nursing Officer.


Based on review of the Pharmacy Agreement and interview, it was determined the Facility failed to have a contract with a Pharmacist for the Pharmaceutical Services provided. By not having an agreement, the Facility could not assure the Pharmacist would take full responsibility for the overall administration of Pharmacy Services. The failed practice had the likelihood to affect all patients who received Pharmacy Services. Findings follow:
A. Review of Pharmacy Agreement on 07/22/14 revealed the contract between [Named Pharmacy] and Dewitt Hospital terminated on February 1, 2005.

B. Findings were verified, through interview, on 07/22/14 at 1510 with the Administrative Assistant.


Based on observation, review of package insert and interview, it was determined the Facility failed to ensure Blood Glucose Controls were not used beyond their expiration date in that one (Emergency Department) of two (Emergency Department and Lab) Blood Glucose testing kits had both bottles of control solutions (Control level 1 & Control level 2) that were not dated when opened. By not dating the Control Solutions when opened, the Facility could not assure the Blood Glucose Meters were performing acceptably. The failed practice had the likelihood to affect all patients who received treatment based on blood sugar levels. Finding follow:
A. During a tour of the Facility on 07/21/14 between 1316 and 1520, observation revealed the following: Emergency Department's Blood Glucose Monitoring Kit had both control solutions opened, but not dated when opened or dated with expiration date (90 days once opened).

B. Review of package insert on 07/21/14 revealed the following: "Note: Write the date the bottle was opened on the bottle label. The control solution is stable for 3 months from that date or until the 'use by' date on the bottle label, whichever comes first."

C. Findings were verified with Director of Emergency Services on 07/21/14 at 1458

Based on observation and interview, it was determined recliners in 4 (#117, 118, 110 and 108) of 8 patient rooms were covered with a fabric material with frayed and worn areas that exposed the padded surfaces beneath. The material and exposed frayed areas did not allow disinfection between patients and had the potential to cause infection. The failed practice affected any patient admitted to the affected rooms. The findings were:
On 07/21/14 at 1315 recliners were noted in patient rooms 117, 118,110 and 108. The recliners were covered in a cloth type material with worn areas in the fabric that exposed the padding material beneath. The porous fabric and exposed padding could not be sanitized between patients. The findings were confirmed by interview with the Chief Nursing Officer on 07/21/14 at 1345.


Based on observation, review of Autoclave Sterility Log, policy and procedure and interview, it was determined the Facility failed to follow their policy for monitoring the efficacy of the sterilization of instruments performed off site. There was no documentation of the results of biological spore testing as identified in the Facility policy. The failed practice was likely to affect any patient that sterile non-disposable instruments were used on. The findings were:

A. On 07/22/14 at 1415, Employee #2 and Employee #1 were interviewed and the Autoclave Sterility Log was reviewed. The Facility has not had an in-house autoclave or performed in-house sterilization of instruments since 09/12/12 as documented on the log and by interview. Employee #1 and #2 stated the items are pre-cleaned at the Facility and wrapped. The wrapped packages are taken to another hospital to be sterilized. The items are returned "sterilized and in a dust cover".

B. Review of policy and procedure "Sterile Supply: Autoclave" revealed the statement "(Facility Named) does not have a functional autoclave for sterilizing instruments. An agreement with (Facility Named) allows this facility to clean and package instruments per policy and deliver them to (Named) hospital for sterilization. The instruments are sterilized per (Facility Named) and returned to this Facility for final packaging by the Central Supply Technician. Copies of autoclave controls and temperature logs will also be provided per (Facility Named) to insure proper sterilization has been performed." The policy and procedure was dated 09/10/13.

C. A Policy and Procedure dated 02/2013 stated "The following protocol will be followed for sterilization until further notice: Instruments will be cleaned, dried and placed in Central Supply. Central Supply Technician will wrap instruments accordingly and be transported to (Facility Named) for sterilization. Instruments are then packaged, labeled and sealed. Spore checks, Tec test and S.M.A.R.T are sent from (Facility Named) to ensure proper sterilization is performed."

D. By interview with Employee #1 and #2 on 07/22/14 at 1415 and review of documentation of monitoring of sterilization procedure per policy revealed no evidence of monitoring of biological indicators since 08/05/13. Instruments had been sent out for sterilization a total of 22 times to another Facility from 10/31/12 - 07/09/14. Biological Indicators were not reported 15 of 22 times.

E. The findings were confirmed by interview with the Director of Nursing on 07/22/14 at 1430.

Based on policy review, Diet Manual review and interview, it was determined the Facility failed to ensure the Diet Manual was current. The failed practice did not allow staff access to the most current dietary recommendations and had the potential to affect any patient admitted to the Facility. Findings follow.

A. Review of "Diet Manual Use" policy stated, "The 1996 Manual of Clinical Dietetics will be used...".
B. Review of the Manual of Clinical Dietetics being used by the Facility revealed a copyright date of 1996. The cover page revealed an approval date by the Medical Staff of 01/27/14.
C. Review of an additional Dietary Manual titled "Simple Diets for Complex Nutritional Demands" revealed a copyright date of 1997. The cover page revealed an approval date by the Medical Staff of 02/24/14.
D. Findings were confirmed by the Certified Dietary Manager on 07/24/14 at 1045.



Based on policy review, clinical record review and interview, it was determined the Facility failed to ensure five (#3, #5 and #7-#9) of 10 inpatients (#1-#10) received a nutrition screening within 24 hours of admission. Failure to conduct a nutrition screen did not allow staff to know which patients were at nutritional risk and had the potential to affect any patient admitted to the Facility who was at nutritional risk. Findings follow.

A. Review of "Clinical Nutrition Policy" stated, "Nutritional screening will be initiated by trained dietary personnel on all patients to determine nutritional risk within 24 hours of admission."

B. Patient #3 was admitted to the facility on 07/18/14 and discharged 07/21/14. No nutritional screen was documented. Findings were verified by the Care Transition Coordinator on 07/24/14 at 1305.

C. Patient #5 was admitted on 07/21/14. Review of the clinical record revealed the following:
1) Review of the Nutritional Screening Form, under section titled "Category 1 (Automatic Triggers) - Dietitian will evaluate/recommend if one of the following risk factors identified: Serum albumin <2.8 - yes."
2) Under section titled "Category 2-Dietitian will evaluate/recommend if two or more risk factors are identified ...Receives modified diet - yes." Poor oral intake for 3 days or more-no." Review of the History and Physical stated that Patient #5 "had not been eating over the previous four days."
3) The clinical record revealed no evidence the Dietitian evaluated Patient #5, even though Category 1 triggers warranted an evaluation. Patient #5 was transferred to another Facility on 07/23/14.
4) Findings were confirmed by the Care Transition Coordinator on 07/24/14 at 1330.

D. Patient #7 was admitted on 06/27/14 through 06/30/14. No nutritional screening was documented. Findings were verified by Registered Nurse (RN) #1 on 07/24/14 at 1340.

E. Patient #8 was admitted on 07/08/14 through 07/11/14. No nutritional screening was documented. Findings were verified by RN #1 on 07/24/14 at 1355.

F. Patient #9 was admitted on 07/02/14 through 07/04/14. No nutritional screening was documented. Findings were verified by RN #1 on 07/24/14 at 1316.

Based on clinical record review, review of policy and procedure, Medical Staff Bylaws and interview, it was determined the Facility failed to assure a History and Physical was completed for 2 ( Patient #1 and #5) of 21 clinical record patients within 48 hours as required per Facility Policy and Procedure. Failure to assure the History and Physical was completed within the required time frame did not assure the patient history of illness would be available and had the potential to affect all patients admitted to the Facility. The findings were:
A. Patient (Pt) #1 was admitted to the Facility on 07/16/14 at 0918. Clinical record review on 07/24/14 at 0945 revealed there was no History and Physical. The findings were confirmed on 07/16/14 at 0945 by the Care Transition Coordinator.
B. Patient #5 was admitted to the Facility on 07/15/14 at 1405 and discharged on 07/22/14 at 0900. Clinical record review on 07/24/14 at 1320 revealed there was no History and Physical. The findings were confirmed by the Care Transition Coordinator on 07/24/14 at 1320.
C. Review of the Medical Staff Bylaws, "Article XIX: Rules and Regulations" item nine stated, "A complete history and physical examination shall in all cases be done no more than 7 days before or 48 hours after an admission for each patient by the attending physician and placed on the record."