HospitalInspections.org

1. Based on review of the Swing-Bed Policy and Procedure Manual and interview, it was determined the facility failed to maintain current policies and procedures for the Swing-Bed Program. The failed practice had the potential to affect all patients admitted to the Swing-Bed Program. Findings follow:

A. Review of the Swing-Bed Policy and Procedure Manual revealed there was no evidence it had been reviewed and revised since January 2008.
B. Review of the Swing-Bed Policy and Procedure Manual revealed it did not contain the current Policies and Procedures for wound care and restraints. The Manual contained multiple policies and procedures for bomb threats.
C. Review of the Swing-Bed Policy and Procedure Manual revealed it contained policies and procedures for use of the Minimum Data Set (MDS), which is not required for critical access hospital.
D. Interview on 01/12/10 at 1345, the Swing-Bed Coordinator confirmed the above findings.


13075

2. Based on clinical record review, policy review and interview, it was determined the facility failed to follow its Restraints policy for three (#6, #7 and #17) of three patients reviewed who were in restraints related to physician orders, the plan of care, assessment and monitoring and staff education. The failed practice had the potential to affect all patients in restraints. Findings follow:

A. Review of the Restraints policy revealed restraints were ordered by a physician. The original order would only be renewed in accordance with set time limits for up to a total of 24 hours and there would be no standing or PRN (as needed) orders. The patient's plan of care must have written modification concerning the restraints, and two hour assessments on patients in restraints would be documented on the Restraint form. In addition the Restraints policy stated all new employees would be trained on proper and safe use of restraint application techniques and alternative methods with annual review on application techniques and alternative methods.
B. Review of the physician's orders for Patient #17 revealed an admission order for, "Soft restraints please for safety if needed (family aware of it.)." The order was not time limited and was written as needed. There were no additional orders for wrist restraints or four side rails up.
C. Review of physician's orders for Patients #6 and #7 revealed the lack of an order for restraints.
D. Review of nurses notes and flow sheets revealed the following:
1) Patient #6 was placed in restraints as the four sided rails were up from 1900 on 11/26/09 through 0700 on 11/27/09; from 1900 on 11/27/09 through 0700 on 11/28/09; from 1900 on 11/28/09 through 1900 on 11/29/09; and from 1900 on 11/29/09 through 1200 on 11/30/09.
2) Patient #7 was placed in restraints as the four side rails were up from 700 on 11/01/09 through 0700 on 11/04/09 and from 1900 on 11/08/09 through 0700 on 11/09/09.
3) Patient #17 was placed in restraints as the four side rails were up from 0700 on 11/24/09 through 0700 on 11/25/09 and from 1900 on 11/25/09 through 0700 on 11/27/09.
4) Review of the nurses notes for Patient #17 revealed documentation at 0415 on 11/24/09 stating, "Patient has on wrist restraints for patient safety." The nurses notes lacked any reference to removing the wrist restraints; the wrist restraints were not reflected on the flow sheets.
E. Review of the plans of care for Patients #6, #7 and #17 revealed the lack of a reference to restraints.
F. Review of the Restraint forms for Patient #6, #7 and #17 revealed no documentation of assessment and monitoring while the patients were in restraints.
G. The Director of Nurses confirmed the above during interview at 0910 on 01/14/10.
H. No evidence of restraint education was provided during the survey. The Director of Nurses stated at 0920 on 01/14/10 there had been no restraint education provided since she came to the facility and she was unable to locate any evidence of restraint education prior to that time.

3. Based on Pharmacy Policy and Procedure Manual review, observation, and interview, the facility failed to ensure outdated medications were not available for patient use in four of four patient medication storage areas (South Wing Nursing Unit, Swing Bed Nursing Unit, Emergency Department, and Endoscopy Suite). The potential existed for patients to receive outdated medications in these patient care areas. Findings follow:

A. The Pharmacy Policy and Procedure Manual was reviewed on 01/12/10 at 1500. Policy #3.5.22 reflected the Director of Pharmacy or designee would remove outdated medications from patient care areas monthly, and the medications would be quarantined in the Pharmacy.
B. A tour of the facility's four patient medication storage areas was conducted on 01/12/10 between 1025 and 1400. The following outdated medications were observed:

Swing Bed Nursing Unit
1) Two ampules of Isuprel expired 01/01/10.

South Wing Nursing Unit
1) Eleven Vitamin K1 10 milligrams (mg)/milliliter (ml) expired 12/01/09;
2) Five Vitamin K1 10 mg/ml expired 10/01/09;
3) Sixteen Atropine 0.4 mg/ml expired 10/09;
4) Two Epinephrine 1 mg/ml expired 10/01/09;
5) One Verapamil 4 ml expired 01/01/10;
6) One Verapamil 2 ml expired 10/01/09;
7) One Dexferrum expired 07/09;
8) A partial bottle of Lidocaine Viscous 2% expired 06/09;
9) A partial pint of Geri-Vito expired 03/09;
10) One 500 ml 0.9% Sodium Chloride Intravenous Solution expired 07/09; and
11) One Diltiazem 50 mg/10ml expired 08/09.

Emergency Department
1) Seven Verapamil 4 ml expired 01/01/10; and
2) One 1000 ml Dextrose 5% Intravenous Solution expired 11/09.

Endoscopy Suite
1) Two Calcium Chloride 10% expired 01/01/10;
2) One Metoprolol 5 ml expired 01/01/10; and
3) One 1000 ml 0.9% Sodium Chloride Intravenous Solution Expired 11/09.

C. Interviews with the Director of Nursing (DON) were conducted on 01/12/10 between 1025 and 1400 in which the DON verified the medications were outdated.

4. Based on observation and interview, the facility failed to ensure medications labeled as "single use only" were disposed of after one use on three of four patient medication storage areas (Swing Bed Nursing Unit, South Wing Nursing Unit, and Emergency Department) and were available for patient use. The potential existed for patients on the three patient care areas to receive medications from opened vials labeled "single use only" which could be contaminated due to the lack of bacteriostatic agents. Findings follow:

A. A tour of the facility's four patient medication storage areas was conducted on 01/12/10 between 1025 and 1400. The following "single use only" medications were observed on three of four nursing units:

Swing Bed Nursing Unit
1) One Potassium Chloride 40 milliequivalents (meq).

South Wing Nursing Unit
1) Two Sterile Water 10 ml for Injection;
2) Two Potassium Chloride 40 meq;
3) One 50 ml Sodium Chloride 0.9%; and
4) Two 50 ml Magnesium Sulfate.

Emergency Department
1) One Amidate; and
2) One 50 ml Magnesium Sulfate.

B. Interviews with the Director of Nursing (DON) were conducted on 01/12/10 between 1025 and 1400 in which the DON verified the opened "single use only" vials of medications had not been disposed of and were available for patient use.

5. Based on observation and interview, the facility failed to ensure multi-dose vials of medications were dated upon initial entry so the medications could be disposed of in the time period designated by manufacturer or within 28 days according to current standard of practice in three of four (Swing Bed Nursing Unit, South Wing Nursing Unit, Emergency Department) patient medication storage areas. The potential existed for patients in the three patient care areas to receive medications from multi-dose vials that should have been disposed of. Findings follow:

A. A tour of the facility's patient medication storage areas was conducted on 01/12/10 between 1025 and 1400. The following multi-dose vials of medications were observed lacking a date of initial entry:

Swing Bed Nursing Unit
1) One Lovenox 300 mg/3 ml;
2) One 50 ml Lidocaine 1%;
3) One Dexamethasone 20 mg/5 ml.

South Wing Nursing Unit
1) One Bacteriostatic Sterile Water;
2) One Dexamethasone 20 mg/5 ml;
3) One DepoMedrol 40 mg/ml;
4) One 50 ml Lidocaine 20 mg/ml;
5) One 50 ml Lidocaine 1%;
6) One Marcaine 0.5%;
7) One Lovenox 300 mg/3 ml; and
8) One Phenylephrine.

Emergency Department
One 10 ml Succinylcholine.

B. Interviews with the Director of Nursing (DON) were conducted on 01/12/10 between 1025 and 1400 in which the DON verified the multi-dose vials of medications were not dated upon initial entry so that disposal according the manufacturer guidelines or within 28 days of entry could take place.

6. Based on manufacturer label review, observation, and interview, the facility failed to store Aminophyllin and Labetalol appropriately by protecting from light in one of four patient medication storage areas (South Wing Nursing Unit). The potential existed for patients on the South Wing Nursing Unit to be administered the medications that were not stored according to manufacturer recommendations. Findings follow:

A. The manufacturers' labels for Aminophyllin and Labetalol Injectables were reviewed on 01/12/10 at 1050. Both labels reflected the medications were to be protected from light.
B. On 01/12/10 at 1050, it was observed that three vials of Aminophyllin and one vial of Labetalol were stored at South Wing Nursing Unit but not protected from light.
C. An interview was conducted with the Director of Nursing (DON) on 01/12/10 at 1055 in which it was verified the medications were being stored exposed to light.

7. Based on review of the Infection Control Policy and Procedure Manual, the personnel file for the designated Infection Control nurse, and interview, it was determined the facility failed to: have a policy in place for infection control and isolation precautions based on current CDC (Centers for Disease Control) Guidelines; have a policy in place for the use of Alcohol based hand sanitizers; assure there was a system in place for controlling infections and communicable disease of facility personnel, and assure the person designated responsible for Infection Control had infection control training. The failed practice had the potential to affect all patients who receive care at the facility. Findings Follow:

A. The facility Infection Control Policy and Procedure Manual was reviewed on 01/14/10. The CDC guidelines referenced and included in the Policy and Procedure Manual was dated 1997. The current CDC document "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007" was not referenced or provided in the current facility Policy and Procedure Manual. The Policy and Procedure Manual had a review date of 2008.
B. The facility Infection Control Policy and Procedure Manual was reviewed on 01/14/10. There was no Policy or Procedure for the use of Alcohol based hand sanitizer. Observation on 01/12/10 at 1000 revealed alcohol based hand sanitizer dispensers were observed in patient care areas.
C. The facility Infection Control Policy and Procedure Manual was reviewed on 01/14/10. There was no process in place for monitoring or controlling infections and communicable disease of facility personnel.
D. The personnel file for the Licensed Practical Nurse identified as responsible for infection control was reviewed on 01/13/10 and did not contain evidence of training or experience specific for infection control.
E. The findings were confirmed by interview with the Infection Control Nurse and Director of Nursing on 01/14/10 at 1045.

8. Based on review of clinical records, policy and procedure "Skin Care and Prevention of Pressure Sores" and interview, it was determined of the three Swing-Bed patients one (#1) had decubitus ulcers which were not accurately assessed by the nursing staff and as treatment was changed there was no written physician's order for the change. The failed practice had the potential to affect all patients on the Swing-Bed program. Findings follow:

Review of Swing-bed clinical record for Patient #1 revealed there was a discrepancy in the description of the decubiti therefore, it could not be determined if the decubiti had declined, was maintained or improved and there was no physician's orders for change in treatment as follows:
A. The patient was admitted to the Swing-Bed Program on 12/18/09. Review of the Decubitus/Pressure Ulcer Report revealed the section with the anatomical drawing on 01/3/10 reflected there was a Stage II decubitus on the coccyx (Site A) measuring 1 centimeter with no drainage or odor and a Stage II decubitus on the upper left buttock (Site B) measuring 0.5 centimeter with no drainage or odor. Documentation on the description portion of the Decubitus/ Pressure Ulcer Report identified site A was a Stage I decubitus and site B as a Stage I with the measurements the same. The physician ordered wound care to coccyx and left gluteal cheek. Cleanse with normal saline, pat dry, apply skin prep cover with DuoDerm Extra Thin Spots.
B. On 01/06/10, documentation on the Decubitus/Pressure Ulcer Report identified site A as a Stage II decubitus measuring 3.0 centimeters and site B was a Stage II measuring 1 centimeter.
C. On 01/09/10, documentation on the Decubitus/Pressure Ulcer Report identified site A as a Stage II decubitus measuring 3.0 centimeters with moderate drainage and site B was a Stage I measuring 1.0 centimeter which was pink in color with no odor or drainage. The decubiti were cleaned with normal saline and patted dry, Aquagel applied and covered with DuoDerm. Review of the physician's orders revealed there was not an order change the treatment.
D. On 01/11/10, there was no documentation on the Decubitus/Pressure Ulcer Report of the sites, Stages, sizes, depth, drainage, color, or odor for the decubiti. The documentation reflected the Decubiti were cleaned and PolyMem with Mefix tape was applied. Review of the physician's orders revealed there was not an order for the change in treatment.
E. Review of the care plan revealed the decubiti were not addressed.
F. Review of the Daily Assessment form revealed:
1) The patient's decubiti were not documented on the Daily Assessment form on 01/03/10; 01/06/10; 01/09/10 and 01/10/10.
2) The decubitus on the left gluteal check was not documented for 01/03-01/12/10.
G. Interview at 1045 on 01/13/10, the Swing-Bed Coordinator confirmed the above findings.

10. Based on review of the Organizational Quality Assurance/Performance Improvement Plan, Governing Body Committee Meeting minutes and interview, it was determined the Quality Assurance/Performance Improvement Plan was not reviewed and evaluated for its effectiveness by the Governing Body yearly. The failed practice had the potential to affect all patients. Findings follow:

A. Review of the Governing Body Committee Meeting minutes for May 2009 through November 2009 revealed there was no evidence the Quality Assurance/Performance Improvement Plan was reviewed and evaluated for its effectiveness.
B. Review of the Organizational Quality Assurance/Performance Improvement Plan revealed the plan would be evaluated by the Governing Body annually. The Organizational Quality Assurance/Performance Improvement Plan was last reviewed and evaluated by the Governing Body 01/28/08.
B. Interview with the Administrator at 1455 on 01/12/10 confirmed Quality Assurance/ Performance Improvement Plan was not presented to the Governing Body.

11. Based on review of Governing Body Committee Meeting minutes for January through November 2009 and interview, it was determined Quality Assurance/Performance Improvement activities were not reported to the Governing Body quarterly. The failed practice had the potential to affect all patients admitted to the facility.

A. Review of the Governing Body Committee Meeting minutes for January through November 2009 revealed there was no evidence of Quality Assurance/Performance Improvement activities being reported to the Governing Body quarterly.
B. Interview with the Administrator at 1455 on 01/13/10 confirmed Quality Assurance/ Performance Improvement activities were not discussed during the Governing Body Committee Meetings due to the fact the meetings were attended by the local media and local citizens.

12. Based on review of the Activity Director's personnel file and interview, it was determined the facility did not have an Activity Director qualified by education or experience to direct the Activity Program for the Swing-bed patients. The failed practice had the potential to affect all patients admitted to the Swing-bed Program. Findings follow:

A. Review of the Activity Director's personnel file at 1330 on 01/12/10 revealed the individual did not have any training or experience in a Swing-bed Activity Program. Documents in the personnel file referred to the individual as the Materials Manager.
B. Interview with the Swing-bed Coordinator at 1340 on 01/12/10 revealed the individual acting as the Activity Director was the Materials Manager. The Swing-bed Coordinator stated the individual visited each patient daily. The Swing-bed Coordinator was asked what the Materials Manager did with the patients, she replied, "visited with them, talked about old times, played checkers and cards with the patients".